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A 33-year-old female patient presented to a tertiary care hospital Bhopal, India, in 2019 with complaints of left-sided chest discomfort for four months and progressively increasing shortness of breath for one month. The patient developed hoarseness of voice, chest pain and dysphagia one week before presenting to this hospital. The chest X-ray revealed a large homogenous opacity in the left hemithorax with tracheal and cardiac deviation to the right side [Figure 1A]. A contrast enhanced computed tomography of the thorax revealed a single large heterogeneously enhancing soft tissue mass lesion occupying the entire left hemithorax, measuring 27 × 14.6 × 15.5 cm [Figure 1B]. The lesion had caused a significant mass effect in the form of a gross contralateral mediastinal shift, inferior displacement of the diaphragm, anterior displacement of the spleen, encasement and obliteration of the left pulmonary artery and abutment and displacement of the left subclavian artery, arch of aorta and descending aorta without any luminal narrowing. No obvious bony lytic or sclerotic lesion was noted. Open in a separate window Figure 1 A:Chest radiography showing the left hemithorax (whiteout) and gross contralateral shifting of mediastinal structures andB:Computerised tomography of the thorax (mediastinal window) at level T-5 showing a huge mass lesion virtually replacing the left lung and gross contralateral shifting of mediastinum in a 33-years-old female patient with Askin’s tumour. The mass lesion also shows various necrotic areas interspersed in between. An ultrasonography-guided fine needle aspiration cytology of the lesion revealed a malignant round cell tumour, potentially qualifying as a primitive neuroectodermal tumour (PNET). A biopsy of the lesion revealed malignant round cell tumour [Figure 2A]. Immunohistochemistry of the lesion was positive for cluster of differentiation (CD)99 [Figure 2B]. The lymphoid markers—Wilms’ tumour 1 gene and epithelial membrane antigen—were negative. Apart from CD99 positivity, the characteristic site and morphology of the tumour supported the diagnosis of PNET. No blasts were observed on peripheral blood and bone marrow examination, excluding the possibility of lymphoblastic malignancy. There was also no sign of desmoplasia in the tumour stroma thereby excluding the diagnosis of a desmoplastic small round cell tumour. The patient was started on chemotherapy with a VAC-IE (vincristine, adriamycin, cyclophosphamide followed by ifosfamide and etoposide) regimen on the advice of a multi-disciplinary team. Serum lactate dehydrogenase (LDH) level was at 904 U/L. A bone marrow aspiration and biopsy done for staging purposes revealed hyper cellular marrow with erythroid hyperplasia and mild megalobastosis with no evidence of marrow infiltration by tumour cells. The patient’s performance status as per the Eastern Cooperative Oncology Group scale was 3/5. She received her first cycle of chemotherapy as per protocol and supportive treatment in the form of feeding through a nasogastric tube, analgesics and hydration. On the fourth day post-chemotherapy, the patient developed hypoxemic respiratory failure which was managed with supplemental oxygen and antibiotics. However, her condition worsened over the next few days with the patient succumbing to respiratory failure. Open in a separate window Figure 2 Ultrasonography-guided biopsy showing a hypercellular tumour lying in sheets composed of small, round, hyperchromatic tumour cells with scant cytoplasm in a 33-year-old female patient with Askin’s tumour.A:Haematoxylin and eosin stain at ×200 magnification showing tumour cells that are seen encircling lumen forming rosettes at certain places.B:Immunostaining with cluster of differentiation 99 at ×200 magnification showing tumour cells displaying strong membranous positivity. Consent was obtained from the patient’s husband to utilise her case record and images for publication purposes.

IntroductionPositional therapy has been described as add-on therapy to a mandibular advancement device, but the efficacy of combination of positional therapy and positive airway pressure (PPAP) has not been documented. We have found PPAP therapy as an effective method of titration in patients with difficult to treat OSA (obstructive sleep apnea).MethodologyThis retrospective analysis was done in patients who had difficult to treat OSA, i.e., in whom titration in the supine position was unacceptable with any PAP device (CPAP or bilevel PAP) and could only be successfully titrated with a PAP device in the lateral position. This study describes our experience of PPAP therapy. Baseline characteristics and polysomnography data of patients who were successfully titrated in supine v/s lateral positions were compared.ResultsOf 272 consecutive patients with OSA selected for analysis, 218 patients (191 and 27 with CPAP and bilevel PAP, respectively) could be successfully titrated in supine position. Further 54 (20%) patients in whom titration in supine position was unacceptable were titrated in lateral position. Patients titrated with PAP in the lateral position therapy group had higher BMI, higher neck and waist circumference, and lower awake sPO2 and nadir sPO2 during sleep, and spent more time in sleep with sPO2 < 90%.ConclusionCombination of positional therapy and PAP device is an effective way of titration for difficult to treat OSA patients. It can be tried in patients who fail titration in supine position.

An 8-month-old female child, born of a consanguineous marriage, presented to the Paediatrics department, with complaints of excessive weight gain, frequent night-time arousals and decreased sleep. Her elder female sibling died at 18 months of age due to respiratory failure caused by obesity secondary to congenital leptin hormone deficiency. She was referred to the Pulmonary medicine department for level I polysomnography (PSG), which was suggestive of Severe OSA. The mask for the titration study was customised by manually creating exhalation ports in a conventional infant nasal mask. The recommended CPAP pressure was 4.5 cm of H 2 O in the lateral position. Obesity is an important cause of OSA in infants and mutation in the Leptin receptor gene (LEPR) is a cause of early-onset obesity. The evaluation of a suspected case should be thorough with a detailed clinical history and physical examination. Patients should be evaluated with a level I PSG.

Background: Bronchoalveolar lavage (BAL) is a widely accepted investigative tool for the diagnosis of pulmonary lesions. This study was done to find out the usefulness of BAL in diagnosis of pulmonary lesions from central Indian patient population. Methods: A cross-sectional prospective study was performed over a period of three years. All the BAL specimens of patients presenting to Department of Pulmonary Medicine and Tuberculosis during a period of January 2017 to December 2019 were included in the study. Cyto-histopathologic correlation was done, wherever available. Results: Of total 277 cases, there were 178 (64.5%) males and 99 (35.5%) females. The age of patients ranged from 4 years to 82 years. In 92 (33%) cases, specific infective etiology could be identified on BAL cytology, the most common being tuberculosis (26%) followed by fungal infections (2%). Rarely, infections like nocardia, actinomycosis, and hydatidosis were also identified. Eight cases (3%) of malignancy were identified which included two cases of adenocarcinoma, one case of small cell carcinoma, three cases of poorly differentiated carcinoma, and two cases suspicious for malignancy. Some rare diagnoses like diffuse alveolar damage, pulmonary alveolar microlithiasis, and pulmonary alveolar proteinosis could be identified on BAL. Conclusion: BAL is useful in primary diagnosis of infections and malignancies of lower respiratory tract. BAL may aid in diagnostic workup of diffuse lung diseases. A combination of clinical information, high-resolution computed tomography, and BAL analysis may furnish an assured diagnosis to the clinician and obviate need for invasive procedures.

Contrast-enhanced CT scan is the standard imaging for the characterization and evaluation of focal parenchymal lung lesions. It relies on morphology and enhancement patterns for the characterization of lung lesions. However, there is significant overlap among imaging features of various malignant and benign lesions. Hence, it is often necessary to obtain tissue diagnosis with invasive percutaneous or endoscopic-guided tissue sampling. It is often desirable to have non-invasive techniques that can differentiate malignant and benign lung lesions. CT perfusion is an emerging CT technology that allows functional assessment of tissue vascularity through various parameters and can help in differentiating benign and malignant focal lung lesions. The purpose of this study was to assess the role of the CT perfusion technique in differentiating malignant and benign focal parenchymal lung lesions. In this prospective observational study, CT perfusion was performed on 41 patients with focal parenchymal lung lesions from December 2020 to June 2022. The four-dimensional range was planned to cover the entire craniocaudal extent of the lesion, followed by a volume perfusion CT (VPCT) of the lesion. A total of 27 dynamic datasets were acquired with a scan interval of 1.5 seconds and a total scan time of 42 seconds. CT perfusion parameters of blood flow (BF), blood volume (BV), and k-trans of the lesion were measured with mathematical algorithms available in the Syngo.via CT perfusion software (Siemens Healthcare, Erlangen, Germany). The median BV in benign lesions was found to be 5.5 mL/100 g, with an interquartile range of 3.3-6.9 and a p-value < 0.001. The median BV in malignant lesions was found to be 11.35 mL/100 g, with an interquartile range of 9.57-13.21 and a p-value ≤ 0.001. The median BF for benign lesions was 45.5 mL/100 g/min, with an interquartile range of 33.8-48.5 and a p-value ≤ 0.001. The median BF for malignant lesion was 61.77 mL/100 g/min, with an interquartile range of 33.8-48.5 and a p-value ≤ 0.001. The median k-trans in the case of benign lesions was found to be 4.2 mL/100 g/min, with an interquartile range of 3.13-6.8 and a p-value ≤ 0.001. The median k-trans in the case of the malignant lesion was found to be 12.05 mL/100g/min, with an interquartile range of 7.20-33.42 and a p-value < 0.001. Our study has also shown BV to have an accuracy of 92.68%, sensitivity of 93.3%, and specificity of 90.01%. Our study has shown that CT perfusion values of BV, BF, and k-trans can be used to differentiate between benign and malignant focal lung parenchymal lesions. K-trans is the most sensitive parameter while BV and BF have greater accuracy and specificity.

Objectives: Some patients with obstructive sleep apnea (OSA) do not respond to Continuous Positive Airway Pressure (CPAP) and for these patients, Bi-level PAP is the next level modality. This study by a theory driven hierarchical approach, tries to identify the predictors for CPAP failure among OSA patients. Methodology: The potential predictors for the model were identified from a theoretical framework rooted in clinical examination, laboratory parameters, and polysomnographic variables pertaining to OSA patients. All patients of OSA who underwent manual titration with CPAP or Bi-level PAP (in case of CPAP Failure) between June 2015 and October 2017 were included in model building. This study compared five competitive models blocks deliberated by increasing order of diagnostic complexity and availability of resources. The fitting of the model was determined by both internal and external validation. Results: Among the five competitive models, the selected model has the significant deviance reduction (−2LL = 121.99, X2 = 25.55, P < 0.0001) from the baseline model (−2LL = 217.356). This logistic regression model consists of the following binary predictors - Age >60 years (odds ratio [OR] = 3.23 [1.27-8.23]), body mass index >35 Kg/m2 (OR = 4.25 [1.78-10.13]), forced expiratory volume <60% (OR = 7.33 [2.83-18.72]), apnea-hypopnea index >75 (OR = 4.31 [1.61-11.56]) and T90 > 30% (OR = 6.67 [2.57-17.36]). Conclusion: These five factors (acronym as BIPAP) may aid to the clinical decision-making by predicting failure of CPAP and therefore may assist in more vigilant clinical care.

A 59-year-old male was initially diagnosed with pemphigus Vulgaris and received rituximab after a suboptimal clinical response with low-dose steroids and cyclophosphamide. Shortly after the third dose, he had acute interstitial pneumonia which was attributed to rituximab as there were no signs of any infective etiology after a detailed workup. He was put on mechanical ventilation but the dramatic response to pulse steroids helped the patient in early extubation and a favorable outcome.

Diffuse alveolar hemorrhage (DAH) has been rarely reported with pulmonary infections and even rarer with pulmonary tuberculosis (PTB). We hereby report the case of a 31-year-old male, a known case of ankylosing spondylitis, who presented with clinical and radiological features consistent with DAH. Initial partial improvement with steroids was followed by a microbiological diagnosis of tuberculosis (TB). Starting of antituberculous treatment was followed by complete clinical improvement. This leads to a thought-provoking possible association between the two pathologies, DAH and PTB, if any.

NOABSTRACTNIV (Non-invasive ventilation) and HFNC (High Flow nasal cannula) are being used in patients with acute respiratory failure. HACOR score has been exclusively calculated for patients on NIV, on other hand ROX index is being used for patients on HFNC. This is first study where ROX index has been used in patients on NIV to predict failure.This study investigates the comparative diagnostic performance of HACOR score and ROX index to predict NIV failure.We performed a retrospective cohort study of non-invasively ventilated COVID-19 patients admitted between 1st April 2020 to 15th June 2021 to ICU of a tertiary care teaching hospital located in Central India. We assessed factors responsible for NIV failure, and whether these scores HACOR/ROX index have discriminative capacity to predict risk of invasive mechanical ventilation.Of the 441 patients included in the current study, 179 (40.5%) recovered, while remaining 262 (59.4%) had NIV failure. On multivariable analysis, ROX index > 4.47 was found protective for NIV-failure (OR 0.15 (95% CI 0.03–0.23; p<0.001). Age > 60 years and SOFA score were other significant independent predictors of NIV-failure. The AUC for prediction of failure rises from 0.84 to 0.94 from day 1 to day 3 for ROX index and from 0.79 to 0.92 for HACOR score in the same period, hence ROX score was non-inferior to HACOR score in current study. DeLong's test for two correlated ROC curves had insignificant difference expect day-1 (D1: 0.03 to 0.08; p=3.191e-05, D2: −0.002 to 0.02; p = 0.2671, D3: −0.003 to 0.04; p= 0.1065).ROX score of 4.47 at day-3 consists of good discriminatory capacity to predict NIV failure. Considering its non-inferiority to HACOR score, the ROX score can be used in patients with acute respiratory failure who are on NIV.