Objective. We aimed to assess the role of medical thoracoscopy in patients with undiagnosed pleural effusion. Methods. Patiens presenting with pleural effusion underwent three pleural aspirations. Patients in whom pleural fluid analysis was inconclusive underwent closed pleural biopsy for diagnostic confirmation. Patients in whom closed pleural biopsy was incolcusive underwent medical thoracoscopy using a rigid thoracoscope with a viewing angle of zero degrees was done under local anaesthesia and sedation with the patient lying in lateral decubitus position with the affected side up. Biopsy specimens from parietal pleura were obtained under direct vision and were sent for histopathological examination. Results. Of the 128 patients with pleural effusion who were studied, pleural fluid examination established the diagnosis in 81 (malignancy 33, tuberculosis 33, pyogenic 14 and fungal 1); 47 patients underwent closed pleural biopsy and a diagnosis was made in 28 patients (malignancy 24, tuberculosis 4). The remaining 19 patients underwent medical thoracoscopy and pleural biopsy and the aetiological diagnosis could be confirmed in 13 of the 19 patients (69%) (adenocarcinoma 10, poorly differentiated carcinoma 2 and mesothelioma 1). Conclusion. Medical thoracoscopy is a useful tool for the diagnosis of pleural diseases. The procedure is safe with minimal complications.

Background. Most of the Indian studies on prediction equations for spirometry in adults are several decades old and may have lost their utility as these were carried out with equipment and standardisation protocols that have since changed. Their validity is further questionable as the lung health of the population is likely to have changed over time. Objective. To develop prediction equations for spirometry in adults of north Indian origin using the 2005 American Thoracic Society/European Respiratory Society (ATS/ERS) recommendations on standardisation. Methods. Normal healthy non-smoker subjects, both males and females, aged 18 years and above underwent spirometry using a non-heated Fleisch Pneumotach spirometer calibrated daily. The dataset was randomly divided into training (70%) and test (30%) sets and the former was used to develop the equations. These were validated on the test data set. Prediction equations were developed separately for males and females for forced vital capacity (FVC), forced expiratory volume in first second (FEV1), FEV1/FVC ratio, and instantaneous expiratory flow rates using multiple linear regression procedure with different transformations of dependent and/or independent variables to achieve the best-fitting models for the data. The equations were compared with the previous ones developed in the same population in the 1960s. Results. In all, 685 (489 males, 196 females) subjects performed spirometry that was technically acceptable and repeatable. All the spirometry parameters were significantly higher among males except the FEV1/FVC ratio that was significantly higher in females. Overall, age had a negative relationship with the spirometry parameters while height was positively correlated with each, except for the FEV1/FVC ratio that was related only to age. Weight was included in the models for FVC, forced expiratory flow (FEF75) and FEV1/FVC ratio in males, but its contribution was very small. Standard errors of estimate were provided to enable calculation of the lower limits of normal and standardised residuals for these parameters. The equations were found to be valid on the test dataset, and therefore, may be extended to general population. Comparison with the 1960s equations revealed lack of good agreement, and substantially higher predicted FVC with the current equations, especially in the forty-years-plus age group, in both males and females. Even in the age group upto 40 years, the level of agreement was clinically not acceptable. Conclusions. Validated prediction equations have been developed for spirometry variables in adults of north Indian origin using the current ATS/ERS spirometry standardisation recommendations. The equations suggest an improvement in the lung health of the population over time in the middle-aged and the elderly. These equations should address a long-felt unmet need and enable a more appropriate evaluation of spirometry data in different chest diseases in Indian subjects.

Aim. This study was undertaken to find out the characteristics of clinical, radiological and functional changes affecting the respiratory system in patients with systemic sclerosis (SSc) from eastern India, and the association of these characteristics with pulmonary hypertension. Methods. This was a cross-sectional, observational study involving 46 patients. Other than the routine tests, anti-nuclear antibody (ANA), spirometry, diffusing capacity of lung for carbon monoxide (DLCO) measurement, chest radiograph, highresolution computed tomography (HRCT) of thorax, 6-minute walk test and echocardiography were done. Results. Out of a total of 46 patients, 27 patients had diffuse cutaneous SSc (dcSSc) and 19 had limited cuteaneous SSc (lcSSc). Eleven patients had pulmonary hypertension. The HRCT revealed diffuse parenchymal lung disease (DPLD) in 32 (65%) cases. The ANA was positive in 83% cases. Anti-Scl70 was found in 41% of patients with dcSSc and anti-centromere antibody was found in 47% of patients with lcSSc. Spirometry revealed restrictive pattern in 30 patients; 9 had obstruction; and the rest were normal. The DLCO was abnormal in 38 patients. A strong correlation was found between reduction in DLCO and pulmonary artery systolic pressure (PASP). Also, a strong association was observed between a drop of > 4% in oxygen saturation on 6-minute walk test and presence of pulmonary arterial hypertension (PAH). Conclusions. Majority of the patients with SSc had restrictive lung disease with abnormal DLCO and features resembling non-specific interstitial pneumonia. Nucleolar ANA was predominantly found in patients having PAH. Presence of DPLD had a negative association with presence of anti-centromere antibody. Reduction in DLCO and a fall of > 4% in oxygen saturation on 6-minute walk test may be used as predictors of PAH in asymptomatic individuals.

Multidrug resistant tuberculosis (MDR-TB) has been an area of growing concern and is posing a threat to the control of tuberculosis (TB). The exact magnitude of problem of resistance to anti-tuberculosis drugs worldwide was not known till the 1994-97 global project on anti-tuberculosis drug resistance surveillance initiated by the World Health Organization (WHO) and International Union Against Tuberculosis and Lung Diseases (IUATLD). The Global Tuberculosis Report 2014 estimated that an 3.5% of newly diagnosed and 20.5% of previously treated TB cases had MDR-TB. It has been estimated that 480,000 cases emerged and 210,000 deaths occurred due to MDR-TB globally in 2013. In India, estimates showed that the prevalence of MDR-TB among new and previously treated patients was 2.2% and 15%, respectively. It is estimated that 99,000 cases of MDR-TB emerge every year of which 62,000 were among notified cases of TB in 2013. The MDR-TB is a human-made problem and results largely from poorly managed cases of TB. Adequate, timely diagnosis and optimal treatment of MDR-TB will help curb the epidemic. Efforts must be focused on the effective use of anti-tuberculosis drugs in every new patient, so as to prevent the emergence of MDR-TB.

A 28-year-old, non-smoker pregnant woman who was initially diagnosed to have deep vein thrombosis and pulmonary thromboembolism earlier in pregnancy, presented at 22 weeks of gestation with dyspnoea, visual loss initially in the right eye and then in the left eye. Fundoscopic examination revealed metastatic foci, suggestive of choroid metastases. Computed tomography of the chest revealed a right hilar mass. Fibreoptic bronchoscopy and bronchoscopic biopsy confirmed lung adenocarcinoma. As the patient and family wished to continue with the pregnancy, chemotherapy with cisplatin and was administered from the 31st week of pregnancy and she had undergone Caesarian section in the 32nd week and the baby was healthy. We report this case as it is probably the first reported case of lung cancer presenting with choroidal metastasis in a pregnant woman.

We describe a case of a 90-year-old male admitted to the emergency department with deep vein thrombosis and central acute pulmonary embolism. Despite a remarkably increased value of D-dimer and a modestly elevated concentration of cardiac troponin I, the value of B-type natriuretic peptide was found to be non-diagnostic. Limited to this single case report, our evidence suggests that the measurement of natriuretic peptides is questionable for diagnosing central acute pulmonary embolism in the emergency department.

Thymic carcinoids are rare mediastinal tumours. These are aggressive tumours that often present late and have poor prognosis. Primary surgical treatment is recommended even in metastatic tumours since the role of adjuvant therapy is not well established. We present a case of metastatic thymic carcinoid managed with surgical excision.

Pulmonary capillary haemangiomatosis (PCH) is a rare disorder of unknown aetiology, characterised by proliferating capillaries that invade the pulmonary interstitium, alveolar septae and the pulmonary vasculature. It is often mis-diagnosed as primary pulmonary hypertension and pulmonary veno-occlusive disease. Pulmonary capillary haemangiomatosis is a locally aggressive benign vascular neoplasm of the lung. We report the case of a 19-year-old female who was referred to us in the early post-partum period with severe pulmonary artery hypertension, which was diagnosed as PCH by open lung biopsy.

E-cigarettes are devices designed to deliver nicotine to users without burning tobacco. These are being marketed globally as a healthier substitute to the conventional cigarettes and as smoking quitting aids. The use of these devices has increased recently in developed countries with approximately 1.3 million users reported in the United Kingdom in 2013. Perception of these products as a safe alternative, appealing advertisements, and lax regulatory policies have helped gain popularity among the public. Despite all these claims, a debate is on-going because of insufficient scientific data regarding safety and efficacy of e-cigarettes as well as awareness of the potential health hazards. To solve the dilemma, more scientific studies in this field are required. Prompt regulatory response with strict vigilance on marketing and advertising may be desirable in the interest of users and public at large.