Liquid-phase decomposition mechanism for bis(triaminoguanidinium) azotetrazolate (TAGzT).

This work provides new insights for the liquid-phase decomposition of bis(triaminoguanidinium) azotetrazolate (TAGzT). The liquid-phase decomposition process was investigated using a combined experimental and computational approach. Sub-milligram samples of TAGzT were heated at rates of about 2000 K s-1 to a set temperature (230 to 260 °C) where liquid-phase decomposition occurred under isothermal conditions. Fourier transform infrared (FTIR) spectroscopy and time-of-flight mass spectrometry (ToFMS) were used to acquire transmittance spectra and mass spectra of the evolved gas-phase species from the rapid thermolysis, respectively. FTIR spectroscopy was also used to acquire the transmittance spectra of the condensate and residue formed from the decomposition. N2, NH3, HCN, N2H4, triaminoguanidine and 3-azido-1,2,4-triazol-4-ide anion were identified as products of liquid-phase decomposition. Quantum chemical calculations were used for confirming the identity of the species observed in experiments and for identifying elementary chemical reactions that formed these species. Based on the calculated free energy barriers of these elementary reactions, important reaction pathways were identified for the formation of each of the product species.

Interventional Pulmonology: The Role of Simulation Training and Competency-Based Evaluation.

Medical education and training are becoming more complex endeavors as technological and research advancements lead to new tools and methods to care for patients. In recent years, there has been a paradigm shift in medical education to competency-based assessments. Another important recent development in medical education has been the increasing use of simulation-based learning for procedural training. Interventional pulmonology (IP) is a relatively young and rapidly evolving procedural-based subspecialty. There are several well-validated competency-based assessment tools available to measure training adequacy in many of the most commonly performed procedures in IP. These tools have been shown to improve learning curves and training outcomes. The extent of how widely these tools are being used in clinical and educational spheres, however, remains unclear. Moreover, several commonly performed procedures in IP have no or limited validation tools currently available. Standardized training using simulation has also been shown to lead to positive training outcomes as compared with more traditional training models. However, widespread adoption of simulators has been limited due to the cost and availability.

The effect of flow trigger on rapid shallow breathing index measured through the ventilator.

BACKGROUND: The rapid shallow breathing index (RSBI) has the best predictive value to assess readiness for weaning from mechanical ventilation. At many institutions, this index is conveniently measured without disconnecting the patient from the ventilator, but this method may be inaccurate. Because modern ventilators have a base flow in the flow trigger mode that may provide a substantial help to the patient, we hypothesized that the RSBI is significantly decreased when measured through the ventilator with flow trigger even without continuous positive airway pressure (CPAP) and pressure support (PS). METHODS: The RSBI was calculated using the values of minute ventilation and respiratory rate obtained either through the digital display of the ventilator or from a digital ventilometer. The RSBI was measured using 3 different methods: method 1, CPAP and PS both 0 cm H2O with flow trigger; method 2, CPAP and PS both 0 cm H2O without flow trigger; and method 3, using digital ventilometer. RESULTS: A total of 165 measurements per method were obtained in 80 adult patients in the medical intensive care unit (MICU). The RSBI (breaths/min/L) values were 70.2 ± 26.5 with method 1, 85.4 ± 30.3 with method 2, and 80.1 ± 30.3 with method 3. The RSBI was significantly decreased using mechanical ventilation with flow trigger as compared with mechanical ventilation without flow trigger (P < .0001) or digital ventilometer (P < .0001). When method 1 was compared with methods 2 and 3, the RSBI decreased by 17% and 12%, respectively. CONCLUSIONS: The RSBI measurement is significantly decreased by the base flow delivered through modern ventilators in the flow trigger mode. If RSBI is measured through the ventilator in the flow trigger mode, the difference should be considered when using RSBI to assess readiness for weaning from mechanical ventilation.

Acute ATP loss during irreversible electroporation mediates caspase independent cell death.

Irreversible electroporation (IRE) has been reported to variably cause apoptosis, necrosis, oncosis or pyroptosis. Intracellular ATP is a key substrate for apoptosis which is rapidly depleted during IRE, we sought to understand whether intracellular ATP levels is a determinant of the mode of cell death following IRE. A mouse bladder cancer cell line (MB49) was treated with electric fields while increasing the number of pulses at a fixed electric field strength, and pulse width. Cell proliferation and viability and ATP levels were measured at different timepoints post-treatment. Cell death was quantified with Annexin-V/Propidium Iodide staining. Caspase activity was measure with a fluorometric kit and western blotting. A pan-caspase (Z-VAD-FMK) inhibitor was used to assess the impact of signal inhibition. We found cell death following IRE was insensitive to caspase inhibition and was correlated with ATP loss. These findings were confirmed by cell death assays and measurement of changes in caspase expression on immunoblotting. This effect could not be rescued by ATP supplementation. Rapid and acute ATP loss during IRE interferes with caspase signaling, promoting necrosis. Cell necrosis from IRE is expected to be immunostimulatory and may be effective in cancer cells that carry mutated or defective apoptosis genes.

Synchronous carcinoma of thyroglossal duct cyst and native thyroid gland.

The unobliterated portion of embryological thyroglossal duct may present as cystic swelling later in life and may contain functional thyroid follicles. This cyst requires excision along with the entire thyroglossal duct remnant and adjacent portion of hyoid bone. At times, the excised specimen could demonstrate a focus of carcinomatous change inside the cyst wall. Very rarely, this thyroglossal duct cyst carcinoma could be associated with malignancy of native thyroid gland. This case report illustrates an interesting case of synchronous carcinoma of thyroglossal duct cyst and native thyroid gland. It also sheds light on the controversies related to the pathophysiology of such association and the dilemmas surrounding the management of thyroglossal duct cyst carcinoma, with or without concurrent carcinoma of thyroid gland.

Biogenic synthesis of silver anchored ZnO nanorods as nano catalyst for organic transformation reactions and dye degradation.

In this study, we are reporting biogenic synthesis of silver nanoparticles and hydrothermal synthesis of zinc oxide nanoparticles. Using convenient mechanical milling methods, nanocomposites with superior photocatalytic and catalytic properties are synthesized. Herein, we have adopted a green, eco-friendly, and economical route for the synthesis of Ag nanoparticles using Zingiber officinalae rhizome extract in an aqueous solution. The synthesized materials were characterized using UV-Vis spectroscopy, XRD, SEM & FE-SEM, FT-IR, Raman, and a particle size analyzer with zeta potential analysis. The photocatalytic activities of Ag, ZnO and their composites were studied by observing the degradation of methylene blue and crystal violet dyes under natural sunlight. Then the catalytic efficacies of synthesized nanoparticles for various organic transformation reactions were studied. Ag-ZnO nanocomposites were predicted to have improved photocatalytic activity and organic transformation reactions, allowing them to be used in environmental remediation applications.

Synthesis of a Ag/rGO nanocomposite using Bos taurus indicus urine for nitroarene reduction and biological activity.

The present study develops a unique in situ synthesis of a catalytically and biologically active Ag/reduced graphene oxide (rGO) nanocomposite. Herein, we employed Bos taurus indicus urine to synthesize a Ag/rGO nanocomposite in an environmentally benign, facile, economical, and sustainable manner. The elemental composition analysis reveals the presence of Ag, O and C elements. The scanning electron micrograph shows the formation of spherical silver in nanoform whereas rGO is found to be flake shaped with a wrinkled nature. The synthesized nanomaterial and its composite shows a positive catalytic effect in simple organic transformation for the reduction of nitroarene compounds. Investigations were conducted into the catalytic effectiveness of the prepared nanomaterials for diverse nitroarene reduction. Then, using NaBH4 at 25 °C, the catalytic roles of Ag and the Ag/rGO nano-catalyst were assessed towards the catalytic reduction of several environmental pollutants such as 2-, 3- and 4-nitroaniline and 4-nitrophenol into their respective amino compounds. To test their catalytic performance, bio-mimetically synthesized Ag NPs were thermally treated at 200 °C and compared with the Ag/rGO nanocomposite. Furthermore, biomedical applications such as the antibacterial and antioxidant properties of the as-prepared nanomaterials were investigated in this study.

Bos taurus (A-2) urine assisted bioactive cobalt oxide anchored ZnO: a novel nanoscale approach.

In this study, a novel synthetic method for cobalt oxide (Co3O4) nanoparticles using Bos taurus (A-2) urine as a reducing agent was developed. In addition to this ZnO nanorods were produced hydrothermally and a nanocomposite is formed through a solid-state reaction. The synthesized materials were characterized through modern characterization techniques such as XRD, FE-SEM with EDS, DLS, zeta potential, FT-IR, Raman spectroscopic analysis, and TGA with DSC. The free radical destructive activity was determined using two different methods viz. ABTS and DPPH. The potential for BSA denaturation in vitro, which is measured in comparison to heat-induced denaturation of egg albumin and results in anti-inflammatory effects of nanomaterial was studied. All synthesized nanomaterials have excellent antibacterial properties, particularly against Salmonella typhi and Staphylococcus aureus. The composite exhibits excellent antioxidant and anti-inflammatory activities in comparison to pure nanomaterials. This reveals that these nanomaterials are advantageous in medicine and drug administration.

Bio-mimetic synthesis of catalytically active nano-silver using Bos taurus (A-2) urine.

Herein we have synthesized silver nanoparticles (Ag NPs) using liquid metabolic waste of Bos taurus (A-2 type) urine. Various bio-molecules present in cow urine, are effectively used to reduce silver (Ag) ions into silver nanoparticles in one step. This is bio-inspired electron transfer to Ag ion for the formation of base Ag metal and is fairly prompt and facile. These nanoparticles act as a positive catalyst for various organic transformation reactions. The structural, morphological, and optical properties of the as-synthesized Ag NPs are widely characterized by X-ray diffraction spectroscopy, ultraviolet-visible spectroscopy, scanning electron microscope, Fourier transmission infra-red spectroscopy, and atomic force microscopy. The as-synthesized bio-mimetic Ag NPs show potential activity for several reduction reactions of nitro groups. The Ag NPs were also used for degradation of hazardous dyes such as Methylene blue and Crystal violet with good degradation rate constant.

Advanced Diagnostic and Therapeutic Bronchoscopy: Technology and Reimbursement.

Advanced interventional pulmonary procedures of the airways, pleural space, and mediastinum continue to evolve and be refined. Health care, finance, and clinical professionals are challenged by both the indications and related coding complexities. As the scope of interventional pulmonary procedures expands with advanced technique and medical innovation, program planning and ongoing collaboration among clinicians, finance executives, and reimbursement experts are key elements for success. We describe advanced bronchoscopic procedures, appropriate Current Procedural Terminology coding, valuations, and necessary modifiers to fill the knowledge gap between basic and advanced procedural coding. Our approach is to balance the description of procedures with the associated coding in a way that is of use to the proceduralist, the coding specialist, and other nonclinical professionals.

COVID-19 Impact on Interventional Pulmonology Training.

Background: The impact of the coronavirus disease (COVID-19) pandemic extends beyond the realms of patient care and healthcare resource use to include medical education; however, the repercussions of COVID-19 on the quality of training and trainee perceptions have yet to be explored. Objective: The purpose of this study was to determine the degree of interventional pulmonology (IP) fellows' involvement in the care of COVID-19 and its impact on fellows' clinical education, procedure skills, and postgraduation employment search. Methods: An internet-based survey was validated and distributed among IP fellows in North American fellowship training programs. Results: Of 40 eligible fellows, 38 (95%) completed the survey. A majority of fellows (76%) reported involvement in the care of patients with COVID-19. Fellows training in the Northeast United States reported involvement in the care of a higher number of patients with COVID-19 than in other regions (median, 30 [interquartile range, 20-50] vs. 10 [5-13], respectively; P < 0.01). Fifty-two percent of fellows reported redeployment outside IP during COVID-19, mostly into intensive care units. IP procedure volume decreased by 21% during COVID-19 compared with pre-COVID-19 volume. This decrease was mainly accounted for by a reduction in bronchoscopies. A majority of fellows (82%) reported retainment of outpatient clinics during COVID-19 with the transition from face-to-face to telehealth-predominant format. Continuation of academic and research activities during COVID-19 was reported by 86% and 82% of fellows, respectively. After graduation, all fellows reported having secured employment positions. Conclusion: Although IP fellows were extensively involved in the care of patients with COVID-19, most IP programs retained educational activities through the COVID-19 outbreak. The impact of the decrease in procedure volume on trainee competency would be best addressed individually within each training program. These data may assist in focusing efforts regarding the education of medical trainees during the current and future healthcare crises.

A 63-year-old man with recurrent pulmonary infections: a case of Swyer-James Macleod syndrome.

Swyer-James Macleod syndrome is a rare disorder that leads to recurrent respiratory infections. The fibrosis and obstruction of the terminal and respiratory bronchioles, likely caused by respiratory infections in early childhood, prevents normal development of the alveolar bud. Organisms that have been associated with this syndrome include adenovirus, measles, bordetella pertussis, mycobacterium spp, influenza A and mycoplasma. The syndrome is an acquired cause of unilateral emphysema. The diagnosis of the syndrome can be made in infancy or early childhood, but in asymptomatic individuals can be delayed until adulthood and rarely in the elderly. Chest radiographs and computed tomographic (CT) scan can confirm the diagnosis and exclude other possibilities. A case of Swyer- James Macleod syndrome diagnosed at age 63 in a patient with recurrent respiratory infections and a history of childhood pertussis is presented.

Coccidioidomycosis in nonendemic area: case series and review of literature.

Four cases of coccidioidomycosis, diagnosed in New Orleans, are described to illustrate the varied clinical presentation of this infection. The first is an immunocompromised elderly patient presenting with a cavitary lung lesion after travel to Utah. The second, a young immunocompetent patient presenting with acute respiratory distress syndrome after moving from Arizona. The third and fourth, young Hispanic immigrants with acquired immunodeficiency syndrome presenting with respiratory distress and sepsis. These are examples of different presentations, depending on immune competency, and illustrate the challenges in making this diagnosis in non-endemic areas. For two of the three patients who died an autopsy was obtained. We present the cases, show radiographic and pathological findings, and review the current literature on coccidioidomyocosis.

Basic and Advanced Pleural Procedures: Coding and Professional Fees Update for Pulmonologists.

There is an evolution of pleural procedures that involve broadened clinical indication and expanded scope that include advanced diagnostic, therapeutic, and palliative procedures. Finance and clinical professionals have been challenged to understand the indication and coding complexities that accompany these procedures. This article describes the utility of pleural procedures, the appropriate current procedural terminology coding, and necessary modifiers. Coding pearls that help close the knowledge gap between basic and advanced procedures aim to address coding confusion that is prevalent with pleural procedures and the risk of payment denials, potential underpayment, and documentation audits.

Risk Indicators for Hearing Impairment in Neonates.

To identify relation between prevalence of hearing impairment and risk factors at the time of birth in high risk neonates. A year-long study is performed at HBT Medical College and Dr. R. N. Cooper Municipal General Hospital, Vile Parle (west), Mumbai. The Study comprised of 478 high risk babies born between March 2016 and February 2017 and admitted in NICU of the hospital. Out of these 68 babies were either transferred to higher centre or took discharge against medical advice. A total of 410 babies completed the study. Additional 21 eligible babies died in NICU during the study. A Prospective Observational Study is used to analyse the findings of the study. Skew analysis of spread of prevalence across risk factors is used to establish higher prevalence of hearing impairment in high risk neonates. Cramer's Moment Coefficient of Skewness and Corresponding Test Statistics are used for studying the skewness. Out of 410 babies screened during the study 5 babies were diagnosed with profound SNHL. The risk factors associated with babies is plotted against frequency of babies with Profound SNHL. The plot is found to be un-uniformly distributed and shows inclination towards higher prevalence with high risk babies. Sample skewness (G1) value - 0.81 indicates moderately negative skewed sample. This means the number of babies with profound SNHL found by 3 stage screening is moderately concentrated at high risk weightage.

Use of Tracheostomy During the COVID-19 Pandemic: American College of Chest Physicians/American Association for Bronchology and Interventional Pulmonology/Association of Interventional Pulmonology Program Directors Expert Panel Report.

BACKGROUND: The role of tracheostomy during the coronavirus disease 2019 (COVID-19) pandemic remains unknown. The goal of this consensus statement is to examine the current evidence for performing tracheostomy in patients with respiratory failure from COVID-19 and offer guidance to physicians on the preparation, timing, and technique while minimizing the risk of infection to health care workers (HCWs). METHODS: A panel including intensivists and interventional pulmonologists from three professional societies representing 13 institutions with experience in managing patients with COVID-19 across a spectrum of health-care environments developed key clinical questions addressing specific topics on tracheostomy in COVID-19. A systematic review of the literature and an established modified Delphi consensus methodology were applied to provide a reliable evidence-based consensus statement and expert panel report. RESULTS: Eight key questions, corresponding to 14 decision points, were rated by the panel. The results were aggregated, resulting in eight main recommendations and five additional remarks intended to guide health-care providers in the decision-making process pertinent to tracheostomy in patients with COVID-19-related respiratory failure. CONCLUSION: This panel suggests performing tracheostomy in patients expected to require prolonged mechanical ventilation. A specific timing of tracheostomy cannot be recommended. There is no evidence for routine repeat reverse transcription polymerase chain reaction testing in patients with confirmed COVID-19 evaluated for tracheostomy. To reduce the risk of infection in HCWs, we recommend performing the procedure using techniques that minimize aerosolization while wearing enhanced personal protective equipment. The recommendations presented in this statement may change as more experience is gained during this pandemic.

Value-Based Proposition for a Dedicated Interventional Pulmonology Suite: An Adaptable Business Model.

Value-based care is evolving with a focus on improving efficiency, reducing cost, and enhancing the patient experience. Interventional pulmonology has the opportunity to lead an effective value-based care model. This model is supported by the relatively low cost of pulmonary procedures and has the potential to improve efficiencies in thoracic care. We discuss key strategies to evaluate and improve efficiency in interventional pulmonology practice and describe our experience in developing an interventional pulmonology suite. Such a model can be adapted to other specialty areas and may encourage a more coordinated approach to specialty care.

Fiducial marker placement for stereotactic body radiation therapy via convex probe endobronchial ultrasound: a case series and review of literature.

Convex probe endobronchial ultrasound (CP-EBUS) and stereotactic body radiotherapy (SBRT) are valuable tools in the diagnosis, staging, and treatment of thoracic malignancies. With widespread clinical adoption, novel uses of CP-EBUS beyond mediastinal diagnosis and staging continue to be discovered. SBRT is an attractive treatment strategy in early-stage lung cancer and oligo-metastatic disease of the chest when a surgical approach is either not feasible or desirable. Accurate application of SBRT is aided by the placement of radio-opaque fiducial markers (FM) to compensate for respiratory cycle movements. We describe eight patients with central thoracic lesions, either known or suspected to be malignant, who underwent EBUS bronchoscopy with lesion sampling and successful intralesional placement of modified FM via our technique, review the existing literature on this topic, and discuss the nuances of coding and billing aspects of FM placement.

Diagnosis and management of malignant pleural effusions: state of the art in 2017.

Malignant pleural effusion (MPE) is a known complication of both thoracic and extra thoracic malignancies. The presence of MPE regardless of the primary site translates into advanced stage disease. Diagnosis and management of MPE with the goals of palliation and improving quality of life poses a challenge for chest physicians. Recently, multiple studies have made attempts to answer questions regarding optimal management in various clinical scenarios. We will review the current evidence and available options for the management of MPE.