Diagnostic Accuracy of Sonographic Septations in Tuberculous and Malignant Pleural Effusions

Background: Discrimination between tuberculous (TB) and malignant pleural effusions is a real practical challenge because both exist as exudative lymphocytic type. Transthoracic ultrasonography not only identifies and quantifies pleural effusion but also displays sonographic septations, which are frequently seen in TB pleural effusions and can help in differentiation between tuberculosis and malignancy successfully, without any invasive procedure. We designed this study to determine the diagnostic usefulness of these septations for tuberculous and malignant pleural effusions. Material and Methods: This prospective study was conducted in the OPD of Gulab Devi Chest Hospital Lahore, Pakistan, a 1500 bedded tertiary care hospital, from November 2016 to February 2018. Total of 339 consecutive cases, aged 14-83 years with radiological evidence of pleural effusion were included in the study. After detailed history, thorough physical examination, radiological, haematological and biochemical findings were recorded. Pleural fluid macroscopic, cytological, microbiologic and biochemical analysis results were also recorded. Ultrasonography was done, septated and non-septated pleural effusions identified and findings were noted. SPSS-16 was used for statistical evaluation. Fisher Exact test was utilized for comparison between TB and malignant cases with P-value < 0.05 taken as significant. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), diagnostic accuracy and positive likelihood ratio were calculated. Results: Out of total 339 cases, 49 (14.45%) were malignant and 290 (85.55%) were non-malignant. In the malignant group, only 03 cases (6.12%) showed sonographic septations. In the non-malignant group, 259/290 (89.31%) cases showed tuberculous etiology and 187/259 (72.20%) of these cases displayed sonographic septations. By considering septations as predictor of TB, statistical analysis revealed a sensitivity of 79.23%, specificity of 92.85%, PPV of 98.42%, NPV of 44.31% and diagnostic accuracy of 81.29%, respectively. Conclusions: Sonographic septations can be a valuable predictor of tuberculosis, in a population with high prevalence of the disease. We found it to be a useful feature in differentiating between a malignant and tuberculous etiology, in exudative lymphocytic pleural effusions. It can be used with confidence in patients who are unfit for interventional procedures

Diagnostic Efficacy of Pleural Fluid Adenosine Deaminase Level in diagnosing TB Pleural Effusion is Excellent in a High Prevalence Area.

Objectives: To evaluate the efficacy of Pleural Fluid ADA level in diagnosing tuberculous pleural effusions.Place and Duration: The study was conducted at the Gulab Devi Chest Hospital Lahore from 03-01-2017 to 30-09-2017.Methodology: 456 cases having age > 14 years and radiological evidence of pleural effusion were included. Patients having Age > 65 years, minimal inaspirable pleural effusion, negative consent for ADA estimation and with obvious radiological signs of malignancy were excluded. Detailed history, physical examination, radiological, haematological and biochemical findings were recorded. Pleural fluid analysis including ADA levels were recorded. Statistics was applied to reach the conclusion.Results: 422/456(92.54%)cases were exudates while 34/456(7.45%) were transudate. 352 cases were diagnosed as TB pleuritis. 330(93.75%)cases showed PFADA levels 40 IU/L and above, while 22 cases showed ADA level < 40IU/L. Mean ADA level for TB peural effusion is 74.43IU/L. Using a cut off value 40 IU/L, we got a sensitivity of 93.75%, specificity 91.42 % and Positive predictive value 98.21% for tuberculosis.Conclusion: Pleural fluid ADA level is a valuable bio-marker for TB diagnosis in an area of high prevalence. It successfully differentiates between tuberculous and non-tuberculous pleural effusion

Bacterial Isolates in Slow Resolving Pneumonias

Background : To study the pattern of bacterial isolates in slow resolving pneumonia (SRP) patients Methods : In this prospective study patients (n=121) fulfilling the criteria of slow resolving pneumonia, having Age > 14 years and radiological evidence of consolidation were included in the study. Patients having Age > 65 < 14 years, not giving consent for Invasive investigation, nosocomial pneumonia, atypical pneumonia, fungal and mycobacterial infections were excluded. All patients were investigated with multiple view Chest X-ray, sputum smear for Gram staining, ZN-staining, cytology & culture sensitivity for pyogenic and fungal infections. Fiber-optic Bronchoscopy and BAL analysis was utilized. Contrast enhanced CT scan was employed for accurate definition of the lesion. Samples were sent for microbiological evaluation. Result: Age group was 14-65 years with median age 53 years. One hundred and twenty one pyogenic bacterial isolates were obtained. Gram negative bacteria were 66.11% while gram positive bacteria were 30.57 % and mixed growth were seen in 3.30%. Conclusion : Gram negative etiology predominates in SRP cases with pseudomonas at the top followed by klebsiella

Diagnostic value of HRCT-Thorax for pandemic COVID-19 pneumonia in Pakistan

Background: In the scenario of, inadequate testing, the low sensitivity of the COVID-19-PCR test, limited availability of testing kits, and low detection rate, we aimed to investigate the usefulness of high-resolution computed tomography of chest (HRCT) for diagnosing pandemic coronavirus (COVID-19) pneumonia. Objective: To determine the diagnostic efficacy of HRCT thorax in Covid-19 pandemic pneumonia. Materials and Methods: This prospective, cross-sectional study was conducted in the Pulmonology–OPD of Gulab Devi Teaching Hospital, Lahore-Pakistan from 01-04-2020 to 15-07-2020.   121 patients with dry cough, fever, and dyspnea of sudden onset were included while patients with Bronchial Asthma, ILD, Tuberculosis, Bronchiectasis, COPD, and overt heart failure were excluded. Patients were investigated with chest x-ray, HRCT, COVID-PCR, and hematological tests. HRCT films were evaluated by a qualified and experienced radiologist. Findings were summarized, organized and statistical analysis was done by using SPSS-26 software to make an inference. Results: Five patients were diagnosed as non-covid. Out of 116-diagnosed covid-19 patients, 38(32.75%) showed sub-pleural consolidation, 19(16.37%) consolidation with air-bronchogram, 29(25.0%) crazy paving sign, one pleural effusion (0.86%) and 18 cases (15.51%) displayed reticulations. 11cases(9.48%) had isolated ground glass appearances, while all categories showed it to variable extent. 65 patients (56.03%) were PCR-positive while  51(43.96) patients with positive-HRCT findings for COVID-19 pneumonia had negative nasopharyngeal-PCR. HRCT-Thorax revealed sensitivity: 97.41 %, specificity: 80%, PPV: 99.12%, NPV: 57.14%, and diagnostic accuracy of 96.69% for COVID-19 pneumonia. Conclusion: HRCT-Thorax, having high sensitivity and adequate specificity, can provide foundations for evidence-based early diagnosis and quantification of coronavirus pneumonia.  It can be tremendously useful for decision making in   PCR-negative patients and anticipating respiratory improvement or decline by serial scans

Ultrasound Assisted Pleural Biopsy with Abram Needle is a Valuable Tool in diagnosing Exudative Lymphocytic Pleural Effusions

Objectives: To evaluate the efficacy and safety of US assisted pleural biopsy using Abram Needle. Study Design: A non-randomized prospective study. The study was approved by Ethical Board of Gulab Devi Chest hospital Lahore. Methodology: The study was conducted at the Department of Respiratory Medicine, Gulab Devi Chest Hospital Lahore. 141 male patients with undiagnosed, unilateral, exudative, lymphocytic pleural effusion were included in the study during Jan. 2014 to Nov. 2015. Pleural biopsy was performed with Abram needle after an informed consent, having localized the biopsy point by chest radiographs & sonography.  Tissue samples underwent histopathological evaluation. Diagnosis was made on histopathology reports. Statistics was applied. Results: Six samples were inadequate while 135 were adequate.  31.11% cases were malignant while 68.88% were nonmalignant. Out of 93 nonmalignant cases, 7.52 % were normal pleurae, 46.23% were caseous granulomatous inflammation, 25.80% were chronic nonspecific pleuritis, 10.75 % cases were chronic pleuritis with fibrous thickening, 9.67 % cases were acute pleuritis. Biopsy success rate was 95.74%. All patients tolerated the procedure well. No serious complication occurred. Conclusions:  Abram needle pleural biopsy using ultrasound assistance is very safe and excellent diagnostic tool in diagnosing exudative lymphocytic pleural effusions.  &nbsp

Economics and Marketing of Rose Flowers: A case Study of Islamabad and Rawalpindi Districts

Roses have reasonable demand in Pakistan. The study was conducted in rose growing pockets of Islamabad and Rawalpindi districts. The objective of the study was to determine costs and returns of rose producers and marketing intermediaries. Random sampling technique was used to collect the data from thirty farmers and ten retailers. In the study area, per acre yield of roses was 1010 kg per annum. Average establishment cost of rose gardens was Rs. 0.17 million per acre. Total cost of production was calculated to be Rs. 0.26 million per acre per annum. Gross and net returns of rose farmers were calculated to be Rs. 0.32 million and Rs. 0.06 million per acre, respectively. Benefit cost ratio of roses production was 1.24, thus returns from roses’ production are high enough, and it is an attractive farming activity in the study area. Marketing channel for roses was identified as producers, retailers, and consumers. Marketing costs of producers and retailers were Rs. 54.1 and Rs. 17.3 per kg, respectively. Shares of producers and retailers in consumer rupee were 77.4% and 22.6%, respectively. Farmers in the study area obtain low yield of roses than their counterparts in irrigated areas of the country, mainly to due to traditional non-recommended production practices. Thus, farmers should be trained to use recommended production technology for production of roses

Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P < 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely