HRCT findings of Atypical Adenomatous Hyperplasia.

By Dr Deepu

Focal area of ground glass attenuation on Left Upper Lobe. Rest of the appearances are unremarkable.
 Atypical Adenomatous Hyperplasia (AAH) of the human lung has been recently implicated as a possible precursor lesion of bronchioloalveolar carcinoma (BAC). The atypical adenomatous hyperplasia-adenocarcinoma sequence has been likened to the adenoma-carcinoma sequence in the large intestine. Atypical Adenomatous Hyperplasia is the earliest lesion in stepwise development of bronchioloalveolar carcinoma.By multivariate analysis, sphericity was statistically significantly associated with atypical adenomatous hyperplasia, and internal air bronchogram with bronchioloalveolar carcinoma

Read More: http://www.ajronline.org/doi/full/10.2214/AJR.07.3101

RNTCP comes out with daily regimen for drug sensitive TB

By Dr Deepu

RNTCP India has come out with a new recommendation to use daily ATT in treatment of drug sensitive tuberculosis.

The Revised National Tuberculosis Control Programme (RNTCP) was launched in India in 1997 

based on World Health Organization endorsed Directly Observed Treatment Short-Course (DOTS) 

strategy, employing the thrice weekly treatment regimen.

The Standards for TB Care in India, 2014, which were jointly laid down by Ministry of Health &  Family Welfare, Government of India and World Health Organization, in consultation with experts, based on available evidences and WHO Treatment of TB Guidelines (2010), state that ‘all patients should be given daily regimen. The initial phase should consist of two months of 

Isoniazid (H), Rifampicin (R), Pyrazinamide (Z), and Ethambutol (E). The continuation phase should consist of three drugs, Isoniazid (H), Rifampicin (R) and Ethambutol (E) given for at least 

four months’. The National Technical Working Group (NTWG) on TB/HIV (2013) has recommended use of daily 

regimen using Fixed Dose Combination (FDC) first line TB treatment for PLHIV patients. 

Considering the above, the National Expert Committee to examine type of drug regimen for drug sensitive TB has recommended RNTCP to move towards introducing daily regimen for drug sensitive Tuberculosis in India.

The link to download the guidelines is given below. Please visit the link to download.

Download here

Classification of pneumothorax

By Dr Deepu

Cartoon showing mechanism of pneumothorax

Chest radiograph- right sided pneumothorax

chest radiograph- left sided pneumothorax

Size Classification of Pneumothorax

(A) The American College of Chest Physicians defines the size of a pneumothorax

        by the apex to cupola distance (≥3 cm large; <3 cm small).

(B) The British Thoracic Society defines the size of a pneumothorax

        by the interpleural distance measured at the hilum (≥2 cm large; <2 cm small).

Study: Acetaminophen No Better Than Placebo In Fighting Flu Symptoms

By Dr Deepu

Study: Acetaminophen No Better Than Placebo In Fighting Flu Symptoms .The New York Times (12/9, Bakalar) reports “a randomized trial has found that” acetaminophen “is no more effective than a placebo, with no discernible effect at all on reducing fever or other flu symptoms.” The study was performed by researchers at Medical Research Institute of New Zealand, and is published in Respirology.

It was a randomized, double-blind, placebo-controlled trial of adults aged 18–65 years with influenza-like illness and positive influenza rapid antigen test. Treatments were given with 1 g paracetamol four times a day, or matching placebo, for 5 days. Pernasal swabs were taken for influenza quantitative RT-PCR at Baseline and Days 1, 2 and 5. Temperature and symptom scores were recorded for 5–14 days or time of resolution respectively. The primary outcome variable was area under the curve (AUC) for quantitative PCR log₁₀ viral load from Baseline to Day 5.

They studied  80 participants were randomized: There were 22 and 24 participants who were influenza PCR-positive in placebo and in paracetamol groups respectively. In all participants there were no differences in symptom scores, temperature, time to resolution of illness and health status, with no interaction between randomized treatment and whether influenza was detected by PCR.they therefore concluded that the regular paracetamol had no effect on viral shedding, temperature or clinical symptoms in patients with PCR-confirmed influenza. There remains an insufficient evidence base for paracetamol use in influenza infection.

Chest Challenge: chest x ray spotter

By Dr Deepu
This is a chest X ray of a 60 year old male. Presenting with history of alleged fall and right sided chest pain. His X rays are displayed here. The two X rays are 3 days apart. Observe the X rays and answer these questions.

1.What is your diagnosis?
2.The second X ray has worsened than the first one. What is the cause?
3. What can we expect in the CT thorax?

Signs in chest radiology- The hilum overlay sign

By Dr Deepu

The hilar overlay sign is another sign described by Felson.The hilum overlay sign refers to an appearance on frontal chest X ray of patients with a mass at the level of the hilum which is in fact either anterior or posterior to the hilum.

When a mass arises from the hilum, the pulmonary vessels will be in contact with the mass and hence their silhouette is obliterated. The ability to see and trace the edges of the vessels through the mass implies that the mass is not contacting the hilum, and is therefore either anterior or posterior to it. 

Most of these masses usually are found to be in the anterior mediastinum.

want to read more in chest radiology??? Have a look at the following pages

Chest Radiology

Signs in Chest Radiology

Signs in chest radiology- The silhouette Sign

By Dr Deepu

Silhouette sign/loss of silhouette sign/ loss of outline sign.

I was always confused with the silhouette sign for its hidden meaning and failure to decode it by many medical students. So, I thought it would be apt to unravel it so that it could be handy for many medical students.

One of the most useful signs in chest radiology is the silhouette sign. This sign was described by Dr. Ben Felson. The silhouette sign is in nothing but  elimination of the silhouette or loss of lung/soft tissue interface caused by a mass or fluid in the normally air filled lung. For instance, if an intrathoracic opacity is in anatomic contact with, for example, the heart border, then the opacity will obscure that border. The sign is commonly applied to the heart, aorta, chest wall, and diaphragm. The location of this abnormality can help to determine the location anatomically. 

Just go through the X Ray to know the  various structures seen in the chest x ray.

Let me explain this with this image.

What do we see???

There is plastic bottle which is surrounded by air, the margins of the shadow is very  well demarcated from the surrounding air.

First scenario: There are two bottles, made of same material, placed apart from each other. The shadows appears separate from each other. Let us consider the right bottle to be the heart and the air surrounding the bottle as lung. The left bottle as a mass, since they are far from each other, the border of both  is visible clearly.

Second scenario: Here we see the bottles are touching each other at two points and there is no gap in between and if we look at the shadow, we cannot differentiate between the two shadows, they appear like a single opacity at the upper and lower ends.

For the heart, the silhouette sign can be caused by an opacity in the RML, lingula, anterior segment of the upper lobe, lower aspect of the oblique fissure, anterior mediastinum, and anterior portion of the pleural cavity.

This contrasts with an opacity in the posterior pleural cavity, posterior mediastinum, of lower lobes which cause an overlap and not an obliteration of the heart border. Therefore both the presence and absence of this sign is useful in the localization of pathology.

want to read more in chest radiology??? Have a look at the following pages
Chest Radiology
Signs in Chest Radiology

signs in chest radiology Bulging Fissure Sign

By Dr Deepu

Bulging Fissure Sign

The bulging fissure sign, it represents expansive lobar consolidation causing fissural bulging or displacement by copious amounts of inflammatory exudate within the affected parenchyma, seen in a chest x ray. It is classically associated with right upper lobe consolidation due to Klebsiella pneumoniae , any form of pneumonia can manifest the bulging fissure sign.  The prevalence of this sign is decreasing,because of prompt administration of antibiotic therapy to patients with suspected pneumonia . The bulging fissure sign is also less commonly detected in patients with hospital-acquired Klebsiella pneumonia than in those with community-acquired Klebsiella infection .

   Other diseases that manifest a bulging fissure

 any space-occupying process in the lung, such as

pulmonary hemorrhage,

 lung abscess, and

 tumor

want to read more in chest radiology??? Have a look at the following pages

Chest Radiology

Signs in Chest Radiology

New ATS Guideline Site

By Dr Deepu

New ATS Guidelines.

The ATS has launched a one spot location for all its guidelines. Here you can find the latest ATS guidelines.Please use the guideline central to get all the guidelines.

Titles Include:

• Severe Asthma
• EIB
• Pulmonary Fibrosis
• Sleep Apnea
• PH of Sickle Cell
• Critical Care Series
• and Many More

Click Here to Preview the ATS Pocket Guides

WHO Calls On India To Increase Funding To Fight TB

By Dr Deepu

Reuters (11/19, Kalra) reports that the World Health Organization said that the global fight to end a tuberculosis epidemic by 2030 hinges on India increasing funding to control the disease. Reuters notes that the country accounts for over 20 percent of global TB cases.

        Combating TB is a daunting task in India due to widespread insanitary conditions, poverty and a lack of public hospitals. Low public awareness and social stigma attached to the killer disease also hinder eradication efforts.

India also needs to upgrade laboratories to better detect the disease - the government last year tracked down 25,000 of the WHO's estimated 47,000 multi-drug resistant TB cases that, Raviglione said, was "not sufficient" but better than before.

    TB killed 1.1 million people globally last year, for the first time rivaling HIV/AIDS as a leading cause of death from infectious diseases.

"If India doesn't invest on TB, then there will be very little progress at the global level," said Raviglione.

Arsenic and permissible limits

By Dr Deepu

Arsenic is a semi-metal element in the periodic table. It is odorless and tasteless. It enters drinking water supplies from natural deposits in the earth or from agricultural and industrial practices. 

Non-cancer effects can include thickening and discoloration of the skin, stomach pain, nausea, vomiting; diarrhea; numbness in hands and feet; partial paralysis; and blindness. Arsenic has been linked to cancer of the bladder, lungs, skin, kidney, nasal passages, liver, and prostate.

EPA has set the arsenic standard for drinking water at .010 parts per million (10 parts per billion) to protect consumers served by public water systems from the effects of long-term, chronic exposure to arsenic.  Water systems must comply with this standard by January 23, 2006, providing additional protection to an estimated 13 million Americans.

EPA proposed arsenic regulations to revise the existing NPDWR on June 22, 2000 (65 FR 38888), which proposed a Maximum Contaminant Level (MCL) of 0.005 mg/L (5 μg/L). The October 2000 appropriations bill for EPA amended the SDWA, directing EPA to promulgate a final arsenic standard no later than June 22, 2001. The Final Rule, published on January 22, 2001, established the MCL at 0.01 mg/L (10 μg/L) (40 CFR 141.62(b)(16)). The Rule was to become effective on March 23, 2001, 60 days after publication. The Rule established that the 0.01 mg/L (10 μg/L) MCL becomes enforceable on January 23, 2006, and that the clarifications to compliance and new source contaminants monitoring regulations become enforceable on January 22, 2004 (40 CFR 141.6(j) & (k)).

Because of the importance of the Arsenic Rule and the national debate surrounding it related to science and costs, EPA's Administrator publicly announced on March 20, 2001, that the Agency  would take additional steps to reassess the scientific and cost issues associated with this Rule. EPA requested that the National Academy of Sciences (NAS) convene a panel of scientific experts to review the Agency's interpretation and application of arsenic research, worked with its National Drinking Water Advisory Council (NDWAC) to review the assumptions and methodologies underlying the Agency's estimate of arsenic compliance costs, and asked its Science Advisory Board (SAB) to look at the benefits associated with the Rule. On October 31, 2001, the EPA Administrator announced that the 10 ppb (0.010 mg/L) standard for arsenic would remain stating that, "the 10 ppb protects public health based on the best available science and ensures that the cost of the standard is achievable."

On January 22, 2001 EPA adopted a new standard for arsenic in drinking water at 10 parts per billion (ppb), replacing the old standard of 50 ppb.  The rule became effective on February 22, 2002.  The date by which systems must comply with the new 10 ppb standard is January 23, 2006.

Study: Arsenic Exposure In Womb Linked To Increased Respiratory Infections For Newborns

By Dr Deepu

HealthDay (11/23) reports that a new study published in the journal Environmental Health Perspectives suggests that children exposed to high levels of arsenic in the womb face an increased risk for infections and respiratory symptoms in the first year of their life. Researchers measured levels of arsenic in 412 pregnant women in New Hampshire whose homes and private wells, and they found “infants exposed to arsenic in the womb had more infections that led to a doctor visit or treatment with prescription medications.” senior author Margaret Karagas, chair of epidemiology at Dartmouth College’s School of Medicine, said in a college news release: “These results suggest that arsenic exposure may increase the risk and severity of certain types of infections.”

Read about ARSENIC and its permissible limits

FDA Approves Lung Cancer Drug

By Dr Deepu

The Wall Street Journal (11/25, B6, Steele, Subscription Publication) reports that the Food and Drug Administration announced Tuesday that it had approved Eli Lilly’s lung cancer drug, Portrazza (necitumumab). Portrazza, in combination with two forms of chemotherapy, treats patients who have advanced squamous non-small cell lung cancer and have not already received another treatment for their advanced lung cancer.

        The Indianapolis Star (11/25, Swiatek) reports that the drug “is the first biologic approved to treat patients with metastatic squamous non-small-cell lung cancer.” Although Eli Lilly did not release a price for the drug, the company “said it plans to offer a discount program to offer income-eligible patients a way to receive Portrazza for a copay of no more than $25 a dose.” 

Indicated for first-line treatment of metastatic squamous NSCLC in combination with gemcitabine and cisplatin

800 mg IV infused over 1 hr on days 1 and 8 of each 3-week cycle prior to gemcitabine and cisplatin infusion

Continue therapy until disease progression or unacceptable toxicity.

Mechanism of Action
Epidermal growth factor receptor (EGFR) inhibitor; monoclonal antibody that binds to the human EFGR and blocks interaction between EGFR and its ligands
Expression and activation of EGFR has been correlated with malignant progression, induction of angiogenesis, and inhibition of apoptosis
Pharmacokinetics
Time to steady state: ~100 days
Total systemic clearance at steady-state: 14.1 mL/hr
Vd: 7 L
Half-life: ~14 days

Adverse effects

Infusion-related reactions

1. Grade 1: Reduce the infusion rate by 50%
2. Grade 2: Stop the infusion until signs and symptoms have resolved to grade 0 or 1; resume infusion at 50% reduced rate for all subsequent infusions
3. Grade 3 or 4 IRR: Permanently discontinue

Dermatologic toxicity

·         Grade 3 rash or acneiform rash: Withhold until symptoms resolve to grade ≤2, then resume infusion at reduced dose of 400 mg for at least 1 treatment cycle; if symptoms do not worsen, may increase dose to 600 mg and 800 mg in subsequent cycles

·         Permanently discontinue if

1. Grade 3 rash or acneiform rash do not resolve to grade ≤2 within 6 wk
2. Reactions worsen or become intolerable at a dose of 400 mg
3. Patient experiences grade 3 skin induration/fibrosis
4. Grade 4 dermatologic toxicity

Limitations of use: Not indicated for treatment of nonsquamous NSCLC

Hypomagnesemia (83%)

Hypocalcemia (45%)

Rash (44%)

Hypocalcemia (albumin corrected) (36%)

Hypophosphatemia (31%)

Vomiting (29%)

Hypokalemia (28%)

Hypomagnesemia, grade 3-4 (20%)

Diarrhea (16%)

Dermatitis acneiform (15%)

Weight decreased (13%)

Stomatitis (11%)

Headache (11%)

1-10%

Hemoptysis (10%)

Venous thromboembolic events (9%)

Acne (9%)

Hypophosphatemia, grade 3-4 (8%)

Paronychia (7%)

Conjunctivitis (7%)

Pruritus (7%)

Dry skin (7%)

Hypocalcemia, grade 3-4 (6%)

Hypokalemia, grade 3-4 (5%)

Skin fissures (5%)

Pulmonary embolism (5%)

Venous thromboembolic events, grade 3-4 (5%)

Hypocalcemia (albumin corrected), grade 3-4 (4%)

Vomiting, grade 3-4 (3%)

Diarrhea, grade 3-4 (2%)