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.

Interplay mechanisms between progesterone and endocannabinoid receptors in regulating bull sperm capacitation and acrosome reaction.

After ejaculation, sperm show a limited capacity for transcription and translation. In the oviduct, most of the signalling in sperm is nongenomic and is mediated through membrane receptors. Studies have shown that the cation channel of sperm (CatSper), cAMP, cGMP, protein kinases, and tyrosine phosphorylation are involved in the nongenomic signalling of progesterone (P4) in sperm. However, it is not known whether there is an interplay between P4 and cannabinoid receptors 1 and 2 (CB1 and CB2), transient receptor potential vanilloid 1 (TRPV1), CatSper channels, cAMP, inositol trisphosphate receptor (IP3R), and mitogen-activated protein kinase (MAPK); these potential regulators are involved in the regulation of capacitation and the acrosome reaction. In the present study, selective blockers of CB1, CB2, TRPV1, CatSper channels, cAMP, protein kinase A (PKA), IP3R, and MAPK were used to identify their involvement in P4-mediated bull sperm capacitation and the acrosome reaction. Selective blocking of any one of the molecules caused a significant reduction in P4 signalling (p < 0.05). Interestingly, blocking these molecules in combination followed by treatment with P4 resulted in the complete absence of capacitation and the acrosome reaction. Blocking a single receptor was not able to eliminate the P4-induced capacitation and the acrosome reaction. In addition to the CB1 and CB2 receptors, there may be other signalling pathways that mediate P4 signalling. In conclusion, P4 signalling exhibited interplay with the cannabinoid receptors. The regulation of sperm capacitation and the acrosome reaction also involved cAMP, PKA, l-type and T-type calcium channels, TRPV1, inositol trisphosphate, and MAPK.

Thoracoscopic practices in India-a survey by Indian chest society.

BACKGROUND: Diagnostic thoracentesis is the initial diagnostic investigation in the workup of an undiagnosed Pleural effusion. However, a significant percentage of pleural effusions remain undiagnosed after this step and after closed pleural biopsy. Medical thoracoscopy (MT) has a high diagnostic yield in these patients. MT is now widely practised in India. This survey endeavours to study the practice of this technique by respiratory physicians in India. METHODS: An electronic survey called 'Indian Thoracoscopy survey' was prepared and conducted under the aegis of Indian Chest Society. In all there were 63 Questions in English prepared and disseminated as a "Google Form" to conduct this survey. The subjects were recruited from the e-mail lists of the three major professional surgeries that serve the interests of the respiratory physicians. The participation in the survey was voluntary and no incentive of any sort was offered to the participants. The survey link was kept open for a 3-month period. RESULTS: There were total 659 respondents, whose mean age was 41.5 years and majority of them were males (n = 564, 85.6%). The largest group of respondents practiced in corporate/private hospitals (n = 315, 47.8%). Only 311 (47.2%) respondents performed MT. Of these, 190 (61.1%) used flex-rigid/semi rigid thoracoscopes. Undiagnosed pleural effusions (N = 194; 62.4%) and recurrent pleural effusions (N = 117; 37.6%) were the most common indications for performing MT. Majority of the thoracoscopists (222, 71.4%) used conscious sedation and a combination of Midazolam and Fentanyl was the most preferred combination (n = 238; 76.5%). Most follow the manufacturer's recommendation for thoracoscope cleaning and disinfection and had safety check lists in place. CONCLUSION: Our survey captures the practice of MT in India. MT seems to be increasing in popularity with significant numbers of respiratory physicians performing the procedure. Respondents felt that MT was a valuable investigation that was underused and more of them wanted to learn. It is safe to perform MT under conscious sedation and local anaesthesia and a boon to patients who required surgical procedures for evaluation of difficult to diagnose pleural diseases. The setup cost is significant and would not justify installation in all centres. The lack of opportunities for training is something that needs to be looked in to.

DISPOSABLE COVID BOX - A new invention.

OBJECTIVE: To introduce a new method to do safe bronchoscopy, a highly aerosol generating procedure through disposable COVID box in this difficult COVID time. METHODS: We have introduced an unbelievably cheap and effective method "DISPOSABLE COVID BOX". We took an acrylic board 70 × 20 cm and attached 3 bars 32 cm long and slide it under the side of the patient. A similar contraption is used on the other side. Then, it is covered by a polypropylene sheet 2' × 2'. It makes a completely disposable airtight chamber with the polypropylene sheet. We make a 1 cm nick in the sheet and introduce the video-bronchoscope, which is further navigated into the patient without any discomfort either to the patient or Bronchoscopist. When the procedure is finished, scope is withdrawn from the patient and the polypropylene sheet is squeezed out. The polypropylene sheet is removed and disposed off with all precautions, and the acrylic boards and the bars are cleaned with 1% Sodium hypochlorite solution. This way, the cost is only of polypropylene sheet which is negligible. RESULTS: Videobronchoscopies in indicated patients were done using this novel disposable covid box. This new invention called Disposable COVID box has been practiced for the first time, it's an innovative technique about which we want the world to be known. CONCLUSION: To conclude, there are no aerosols released in atmosphere after the procedure, making it absolutely safe for bronchoscopist and at same time patient also remains safe. We are ready again in no time with fresh polypropylene sheet to do the next bronchoscopy.

Radiology quiz- dancing ball.

We are presenting an interesting case of Pneumonia, who after good initial response deteriorated with recurrent hemoptysis. On culture of bronchial aspirate, patient had coexisting fungal infection and on repeat bronchoscopy showed a unique and rare picture. There was a dancing ball in RUL which was moving. Patient was initially managed conservatively but finally had to undergo lobectomy to achieve permanent cure.

Transbronchial lung cryobiopsy by twin bronchoscopes (kissing technique).

OBJECTIVE: To introduce a new & novel method of obtaining big lung tissue samples by transbronchial lung cryobiopsy by twin bronchoscopes (kissing technique) in an advanced interventional pulmonology suite. METHODS: In patients of diffuse parenchymal lung diseases, transbronchial lung cryobiopsy were taken using this novel approach using simultaneously two bronchoscopes under C- arm guidance under conscious sedation. First, a standard fibreoptic bronchoscope was inserted intranasally and fixed just above the area to be biopsied, then fogarty's catheter was introduced through FOB's suction channel and protruded it at the biopsy site. Second, another video bronchoscope was introduced orally by the side of FOB and cryobiopsy were taken using cryobiopsy forceps. Immediately, Fogarty's catheter was inflated and sealed the opening from where biopsy was taken to stop the bleeding. Third Video bronchoscope was also used which went up to larynx to take photograph of two bronchoscopes kissing each other and entering the vocal cords only, after which it was withdrawn. RESULTS: Transbronchial lung cryobiopsy in patients of diffuse parenchymal lung diseases were taken using this novel approach. This new technique called twin bronchoscopy (Kissing technique) has been practiced for the first time, it's a technique about which we want the world to be known. CONCLUSION: This new and novel two scope kissing bronchoscopy technique for TBLC under conscious sedation can be an alternative and fruitful method, especially the use of Fogarty's catheter to contain intra-bronchial bleeding. There is no deleterious effect on the patient and the patient can be discharged on the same day.

Dynamics of HSPA1A and redox status in the spermatozoa and fluid from different segments of goat epididymis.

The present study was attempted to investigate the dynamics of HSPA1A and redox status in the spermatozoa and fluid of different segments of buck epididymis. Testes were collected from sexually mature and healthy bucks aged between 2 and 3 years. The fluid and spermatozoa from different segments (caput, corpus and cauda) were harvested for further processing and analysis. The concentration of HSPA1A in spermatozoa lysate and epididymal fluid and its relative mRNA expression in spermatozoa from different segments of epididymis were studied. The HSPA1A concentration in epididymal fluid was significantly (P < 0.01) higher in the corpus as compared with caput and cauda, whereas, its concentration and relative mRNA expression decreased significantly (P < 0.01) in the spermatozoa from caput to cauda. The activities of SOD, GR, GST, and concentrations of manoldialdehyde and ROS decreased significantly (P < 0.01) in the spermatozoa from caput to cauda. The glutathione concentration and GPx activity decreased significantly (P < 0.01) in the spermatozoa of cauda as compared with the corpus. The SOD activity and ROS concentration were significantly (P < 0.01) higher in corpus, and GR and GST activity were significantly (P < 0.01) higher in caput fluid as compared with corpus and cauda. It may be concluded that HSPA1A concentration and its relative mRNA expression in spermatozoa decreased progressively, and redox status was altered during transit from caput to cauda.

Endo-bronchial application of glue in the management of hemoptysis.

BACKGROUND: Hemoptysis from varied etiologies, often fails to respond to conservative therapy. The conventional managements of such a situation are Bronchial Artery Embolization (BAE) or thoracic surgery which is often not possible. Endoscopic application of glue may stand as a method of therapy in these circumstances. METHODS: 202 patients of hemoptysis were treated by video-bronchoscopy assisted endobronchial application of glue (n-butyl cyanoacrylate) with the help of polyethylene catheter being placed through the working channel. The details of the procedure and their 6 month follow up are presented. RESULTS: Immediate control of hemoptysis was achieved in 183 i.e. 90.59% of patients. 19 patients had a partial response, i.e., hemoptysis stopped and then recurred, endobronchial application of glue was repeated in them out of which 14 (6.9%) responded to the second procedure whereas 5 (2.47%) failed to show any response in spite of the repeated procedure. The complication rate was 0.49% in the form of glue migrating into the trachea. There was no mortality. CONCLUSION: Endobronchial application of glue for hemoptysis can be an effective, economic and alternative therapy for mild to moderate hemoptysis.

Effect of sericin supplementation on heat shock protein 70 (HSP70) expression, redox status and post thaw semen quality in goat.

Cryopreservation results in substantial deterioration of heat shock protein 70 (HSP70) and ultra-structural changes in sperm organelles, resulting in a marked reduction in post-thaw semen quality. The present study was aimed to explicate the effect of sericin supplementation on expression profile of HSP70, redox status and post-thaw semen quality in Barbari goat. Five Barbari bucks were used to collect thirty semen ejaculates by using artificial vagina and each ejaculate was divided into three aliquots to which sericin was supplemented at 0% (Control), 0.25% (T1) and 0.50% (T2). Further, extended semen samples were equilibrated followed by their cryopreservation. Post-thaw semen characteristics, redox status of seminal plasma, enzyme leakage and HSP70 gene/protein expression in spermatozoa were assessed in all the groups. Per cent progressive motile spermatozoa, spermatozoa having intact plasma membrane (HOST + ve) and intact acrosomes in post-thaw spermatozoa were significantly (p < 0.01) higher in T1 and T2 as compared to control. A significant (p < 0.01) reduction in abnormal spermatozoa was found in T1 as compared to T2. Sericin supplementation significantly (p < 0.05) improved the antioxidative status (SOD, GST, CAT), reduced lipid peroxidation (MDA) and also prevented enzyme (ALT, LDH) leakage as compared to control samples. qRT-PCR results revealed that HSP70 mRNA expression was significantly (p < 0.01) upregulated in T1 and T2 group as compared to control. The positive effect of sericin on expression of HSP70 was further confirmed by immunoblotting followed by densitometry revealing higher expression in T1 and T2 compared to control. Inclusion of 0.25% w/v sericin in semen extender ameliorated the post-thaw semen quality by improving antioxidative status and minimizing the leakage of intracellular enzymes. Sericin supplementation had a beneficial effect on HSP70/HSP70 mRNA expression either by induction or by protection of HSP70/HSP70 mRNA as evident from the gene expression and immunoblotting studies.

Cryo-recanalization in a case of carcinoid tumor - An interesting case report.

The term "cryotherapy" comes from the Greek cryo (κρύο) meaning cold, and therapy (θεραπεία) meaning cure. Cryosurgery is the application of extreme cold to destroy abnormal or diseased tissue. Carcinoid tumors of the lung are a fascinating but uncommon group of pulmonary neoplasms. In the past, these tumors were grouped with benign or less aggressive malignant pulmonary tumors, namely bronchial adenomas. Recent studies have revealed that carcinoid lung tumors are the most indolent form of a spectrum of bronchopulmonary neuroendocrine tumors that, at its extreme, include small cell carcinoma of the lung as its most malignant member. They commonly present as endobronchial obstructions, and if complete, can be life-threatening and require immediate intervention.[1] Recently, we have treated a patient of carcinoid tumor of lung who was managed with cryo-recanalization with excellent response.

Bilateral Pleural Effusion: A Rare Case Report.

A 24-year-old female presented with complaints of distension of abdomen, lower limb swelling and shortness of breath. On examination, she had bilateral pedal oedema, tender mild hepatomegaly, bilateral pleural effusion and ascites. She had received treatment on lines of chronic liver disease, congestive heart failure but did not manifest any improvement. Laboratory investigations including haemogram, echocardiography and liver function testing were inconclusive. Ultrasonography and computed tomography of abdomen revealed obstruction at the junction of inferior vena cava and hepatic vein with pre-stenotic dilatation confirming the diagnosis of Budd-Chiari syndrome. She was treated with balloon dilatation from right femoral vein and the patient showed marked recovery with decrease in ascites and bilateral pleural effusion and improvement in dyspnoea and leg swelling.

Pulmonary Agenesis.

Unilateral opaque lung with ipsilateral mediastinal shift is an uncommon cause of respiratory distress in newborn which can be found on simple radiograph of the chest. Pulmonary agenesis is a rare cause of unilateral opaque lung in the newborn. Nearly 50% cases of pulmonary agenesis are associated with other congenital defects including cardiovascular, skeletal, gastrointestinal or genitourinary systems. We report an infant with agenesis of the right lung associated with other congenital anomalies.

Hemoptysis secondary to actinomycosis: A rare presentation.

We present a 70-year-old female patient who had the history of hypertension and presented with massive haemoptysis. She had been complaining of cough with expectoration and mild streaking of blood in sputum for about 3 days with only crepts in right infrascapular and infra-axillary regions as positive clinical findings. Bronchoscopy revealed a cauliflower-like lesion in the upper- right lobe bronchus; bronchial aspirate showed occasional colonies of gram positive filamentous bacteria surrounded by neutrophils. The Trucut biopsy showed sheets of neutrophils with colonies of filamentous bacteria consistent with actinomycotic infection. She was started on intravenous benzyl penicillin 20 million units 6 hourly. She recovered with no further bouts of hemoptysis and was discharged on amoxicillin + clavulanic acid in a stable condition and she remained under similar condition for more than a year on follow up. Actinomycosis is a rare disease caused by a harmless commensal species, Actinomyces. Diagnosis of actinomycosis is a challenging situation, and more so, very few cases causing hemoptysis have come to light so far.