Transoesophageal bronchoscopic ultrasound-guided fine-needle aspiration (EUS-B-FNA) for left adrenal gland (LAG) sampling: A report of three cases with a review of the literature.

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a standard-of-care modality for evaluating mediastinal lymph nodes and masses. The EBUS bronchoscope may also be introduced through the oesophageal route to perform sampling of accessible lesions, a technique described as transoesophageal bronchoscopic ultrasound-guided fine-needle aspiration (EUS-B-FNA). Because of the central oesophageal approach, EUS-B-FNA provides easy access to the left para-tracheal, subcarinal and para-oesophageal lymph nodes. In addition, the left adrenal gland (LAG) can also be imaged and sampled during the EUS-B-FNA procedure. In patients with suspected lung cancer, accurate staging is essential. Adrenal metastasis is relatively common and may often be a solitary metastatic site. We describe three cases where EUS-B-FNA was performed to safely sample the enlarged LAG in suspected lung cancer. We also review the literature on the performance characteristics of EUS-B-FNA for LAG aspiration.

MicroRNAs in exhaled breath condensate: A pilot study of biomarker detection for lung cancer.

INTRODUCTION: Quantitation of microRNAs secreted by lung cells can provide valuable information regarding lung health. Exhaled breath condensate (EBC) offers a non-invasive way to sample the secreted microRNAs, and could be used as diagnostic tools for lung cancer. MATERIALS & METHODS: EBC samples from twenty treatment-naïve patients with pathologically confirmed lung cancer and twenty healthy subjects were profiled for miRNAs expression. Selected microRNAs were further validated, using quantitative-PCR, in an independent set of 10 subjects from both groups. RESULTS: A total of 78 miRNAs were found to be significantly upregulated in the EBC of lung cancer patients compared to the control group. Six of these 78 miRNAs were shortlisted for validation. Of these, miR-31-3p, let7i, and miR-449c were significantly upregulated, exhibited good discriminatory power. DISCUSSION: Differential expression of miRNAs secreted by lung cells could be quantitated in EBC samples, and could be used as a potential non-invasive tool for early diagnosis of lung cancer.

A review on electronic nose for diagnosis and monitoring treatment response in lung cancer.

Lung cancer is one of the common malignancies with high mortality rate and a poor prognosis. Most lung cancer cases are diagnosed at an advanced stage either due to limited resources of infrastructure, trained human resources, or delay in clinical suspicion. Low-dose computed tomography has emerged as a screening tool for lung cancer detection but this may not be a feasible option for most developing countries. Electronic nose is a unique non-invasive device that has been developed for lung cancer diagnosis and monitoring response by exhaled breath analysis of volatile organic compounds. The breath-print have been shown to differ not only among lung cancer and other respiratory diseases, but also between various types of lung cancer. Hence, we postulate that the breath-print analysis by electronic nose could be a potential biomarker for the early detection of lung cancer along with monitoring treatment response in a resource-limited setting. In this review, we have consolidated the current published literature suggesting the use of an electronic nose in the diagnosis and monitoring treatment response of lung cancer.

microRNAs in exhaled breath condensate for diagnosis of lung cancer in a resource-limited setting: a concise review.

Lung cancer is one of the common cancers globally with high mortality and poor prognosis. Most cases of lung cancer are diagnosed at an advanced stage due to limited diagnostic resources. Screening modalities, such as sputum cytology and annual chest radiographs, have not proved sensitive enough to impact mortality. In recent years, annual low-dose computed tomography has emerged as a potential screening tool for early lung cancer detection, but it may not be a feasible option for developing countries. In this context, exhaled breath condensate (EBC) analysis has been evaluated recently as a noninvasive tool for lung cancer diagnosis. The breath biomarkers also have the advantage of differentiating various types and stages of lung cancer. Recent studies have focused more on microRNAs (miRNAs) as they play a key role in tumourigenesis by regulating the cell cycle, metastasis and angiogenesis. In this review, we have consolidated the current published literature suggesting the utility of miRNAs in EBC for the detection of lung cancer.

Pulmonary-Renal Syndrome: A Real-World Experience From a Tertiary Care Pulmonary Center in North India.

BACKGROUND: Pulmonary renal syndrome (PRS) is a simultaneous occurrence of diffuse alveolar hemorrhage (DAH) and glomerulonephritis (GN). The diagnosis of PRS not only requires a high index of clinical suspicion and prompt management, but it is often fatal due to rapidly progressive clinical deterioration despite aggressive treatment. The authors, therefore, share the real-world experience of PRS presenting to tertiary care pulmonary center in north India. AIMS: The objectives of the study were to identify etiology, clinical manifestations, treatment modalities and outcomes of patients presenting with PRS. MATERIALS & METHODS: This was a retrospective observational study undertaken at Metro Centre for Respiratory Diseases of patients diagnosed with PRS during the last two years between 2019 and 2021. The patients diagnosed with PRS based on clinical manifestations, serology and biopsies were included in the study. All cases of non-immunological causes of PRS were excluded from the study. Chi-square and Mann-Whitney U tests were done to look for associations obtained between survivors and non-survivors. Cox regression analysis was done to estimate the hazard ratios of clinical variables on survival in PRS patients. RESULTS: A total of 12 patients of PRS were included in the study and diagnosis was made based on clinical manifestations, serology as well as biopsies. The mean age of presentation was 45.4 (± 17.8) years and 66.7% of the patients were females. The most common etiology was anti-nuclear cytoplasmic antibodies (ANCA)-associated vasculitis (AAV) seen in 83.3% of the cases. The most common symptoms were coughing and fever (80%) followed by dyspnea and hemoptysis (70%) with the mean duration of symptoms being 17.1 (±8.9) days. The mortality of PRS patients in our study was 41.6% and these patients had a higher acute physiology and chronic health evaluation (APACHE) score (median-26) compared to those patients who survived (median - 15.8). CONCLUSION: The occurrence of PRS, although rare, presents with rapid clinical deterioration leading to a high mortality rate. AAV was the most common cause of PRS as observed in our study. Early recognition and prompt aggressive management strategies with immunosuppressant therapies are essential for better outcomes for the patients.

Endocrine paraneoplastic syndromes in lung cancer: a respiratory physician's perspective.

Lung malignancy is known to be one of the leading causes of cancer-related mortality. Endocrine paraneoplastic syndromes in lung cancer are common. These are due to secretion of various substances and not because of direct tumour invasion or me-tastasis. These syndromes have also been associated with lung cancer prognosis. This review describes the many endocrine paraneoplastic syndromes seen in lung cancer and narrates their incidence, biology, clinical features, diagnosis, and management.

A young immunocompetent female with anterior mediastinal mass.

A 23-year-old female presented with 3 months of central chest pain and fever. Clinico-radiological investigations were consistent with an anterior mediastinal mass. This clinicopathologic conference discusses the differential diagnoses of such a presentation and their management options.

Clinical Microbiology in the Intensive Care Unit: Time for Intensivists to Rejuvenate this Lost Art.

We live in an era of evolving microbial infections and equally evolving drug resistance among microorganisms. In any healthcare facility, intensivists play the most pivotal role with critically ill patients under their direct care. Majority of the critically ill patients already harbor a microorganism at admission or acquire one in the form of healthcare-associated infections during their course of intensive care unit stay. It is therefore rather imperative for intensivists to possess sound knowledge in clinical microbiology. On a negative note, most clinicians have very meager and remote knowledge acquired during their undergraduate years. This knowledge is rather theoretical than applied and wanes over the years becoming nonbeneficial in intensive patient care. We, therefore, intend to explore important concepts in applied microbiology and infection control that intensivists should know and implement in their clinical practice on a day-to-day basis. How to cite this article: Princess I, Vadala R. Clinical Microbiology in the Intensive Care Unit: Time for Intensivists to Rejuvenate this Lost Art. Indian J Crit Care Med 2021;25(5):566-574.

Utility of Bronchiectasis severity index (BSI) as prognostic tool in patients with post tubercular bronchiectasis: An experience from a tertiary care hospital in North India.

BACKGROUND: Bronchiectasis severity Index (BSI) score which predicts the severity of the disease along with future exacerbations and mortality rate has been well validated in European patients; however there is paucity of data evaluating its validity in Indian patients. The authors therefore decided to evaluate the utility of BSI to predict exacerbations and mortality rate in patients with post tubercular bronchiectasis presenting to our facility. METHODS: The study was a retrospective observational study done in patients with bronchiectasis secondary to tuberculosis. These patients were followed up for 4 years. BSI was calculated from different variables and descriptive statistics along with regression analysis were used to evaluate utility of BSI. RESULTS: A total of 48 patients of post tubercular bronchiectasis were included in the study. Majority of our patients belonged to severe bronchiectasis group seen in 23 patients (48%) while those with mild and moderate bronchiectasis were seen in 13 (27%) and 12 (25%) patients respectively. The exacerbation rate in mild group was comparable to the predicted BSI exacerbation at 1 year while the predicted and observed rates were statistically significant for moderate and severe bronchiectasis group (p value < 0.05). Mortality rates at 1 year were comparable in all the groups of bronchiectasis while it was comparable only in mild and moderate group bronchiectasis at 4 years. CONCLUSION: Bronchiectasis severity index seems to predict mortality at 1 year in post tuberculosis bronchiectasis. However, it under predicts 1 year and 4 year exacerbation rates. Hence BSI may not be useful as a prognostic tool in Indian patients with bronchiectasis. Larger multi-centred studies may be required to further evaluate the clinical utility of BSI among Indian population.

Pleural schistosomiasis masquerading as tubercular pyopneumothorax: World's first case report.

Schistosomiasis is an uncommon waterborne helminthic infection that infects humans. Although it is not prevalent in India, many cases are reported due to contact with infested water bodies. Schistosomiasis primarily involves the lower urinary tract and colorectal region. Pulmonary schistosomiasis, although very unusual, has been described with the systemic manifestation of the disease; however, pleural involvement with schistosomiasis has never been described before in the literature. We report this first case of pleural schistosomiasis masquerading as tuberculosis, which posed a diagnostic challenge and later a new learning point in the presentation of the disease.

New twist to an old problem: COVID-19 and idiopathic pulmonary fibrosis.

Iidiopathic pulmonary fibrosis (IPF) diagnosis and treatment during this COVID-19 pandemic have been affected. COVID-19 has not only impacted the prognosis of these patients but also the approach to these patients. Pulmonary function tests (PFT) and lung biopsies are less encouraged now. Traditional antifibrotics used in IPF should be encouraged irrespective of patient lung function and in those with non-definite usual interstitial pneumonia in high resolution computed tomography.

Antimicrobial Stewardship Program in Critical Care-Need of the Hour.

Maximum antibiotic usage within hospitals occurs in critical care areas. Reasons for this usage are the moribund state of patients, invasive devices, and protocol based necessity for empiric antibiotic initiation in most critical conditions. Although unavoidable, prudent use of antibiotics (empiric and therapeutic) should be tailored based on national or if available, unit-based hospital antibiogram. This forms the footstool of every antibiotic policy formulated at tertiary care hospitals. Strict adherence to antibiotic policy formulated based on hospital antibiogram largely benefits patients and hospital-wide antimicrobial stewardship is ensured. The necessity, benefits, key targets, and usefulness of antimicrobial stewardship program (AMSP) in critical care has been elaborated in this review. How to cite this article: Vadala R, Princess I. Antimicrobial Stewardship Program in Critical Care-Need of the Hour. Indian J Crit Care Med 2020;24(9):847-854.

Hospital treatment of severe acute exacerbation of chronic obstructive pulmonary disease in COVID-19 situation: back to basics.

Patients of chronic obstructive pulmonary disease (COPD) during COVID-19 pandemic have higher morbidity. Treatment of these patients require aerosolization procedures like nebulization and noninvasive modalities for ventilation like non-invasive ventilation (NIV) and high flow nasal cannula (HFNC). Role of these procedures in corona virus transmission when treating a case of acute exacerbation of chronic obstructive pulmonary disease should be further studied.

Recurrent non-traumatic idiopathic chylothorax: a diagnostic dilemma with therapeutic challenge.

Chylothorax is an uncommon pleural effusion characterized by the presence of chyle in the pleural space. Malignancy, trauma, and infections such as tuberculosis and filariasis can result in chylothorax. The chyle is an odourless and white liquid; however, around 50% of chylothorax is not milky (serosanguineous) and 10% of chylothorax is idiopathic which can pose a diagnostic dilemma. We propose a systematic approach which includes pleural fluid triglycerides and cholesterol for all undiagnosed pleural effusion. The case highlights the diagnostic dilemma as well as therapeutic challenges.

Tracheobronchial amyloidosis: an uncommon disease with a common presentation.

Amyloidosis is an uncommon heterogeneous and multi-systemic disease characterized by extracellular amyloid deposition. The size of proteins varies and forms a part of local disease or systemic process. Light chain amyloidosis (AL) is the most prevalent form of systemic amyloidosis which may also be seen in localized disease. Isolated tracheobronchial amyloidosis (TBA) is rather unusual with local amyloid deposition which may pose a diagnostic dilemma with subsequent therapeutic challenge. Awareness of such a presentation is crucial in the diagnosis of this rare disease. We describe three cases who presented with haemoptysis, which on further evaluation were diagnosed as isolated TBA, and a review of literature.

Burns in Diabetes Mellitus Patients among Indian Population: Does it Differ from the Rest?

BACKGROUND: Burn injuries in adults can be complicated due to various underlying factors. Of all the co-morbidities complicating wound healing and prognosis of the patient post burn injury, diabetes mellitus is the most common in India. We therefore aimed to explore the epidemiology, interventions, complications, and outcomes in diabetic patients with burn injury. AIM: To analyze demographic characteristics, clinical and microbiological profile and outcome of diabetic burns patients in comparison with nondiabetic burns patients. MATERIALS AND METHODS: This study was a retrospective analysis of diabetic and nondiabetic burns patients admitted to Apollo speciality clinics, Vanagaram, a tertiary care facility in Chennai over a period of 3 years. Data such as age, gender, type and degree of burns, percentage of burns and length of stay, mortality rate, infection rate, type of infections, surgical procedures, and medical complications were analyzed in comparison with nondiabetic burns patients. RESULTS: Among ninety-four burns patients admitted to our hospital over a period of 3 years, 18 patients (19%) were diabetics and 76 patients (81%) were nondiabetics. Mean age of diabetics was 58.2 years (SD-17.1) and nondiabetics was 36.3 years (SD-16.4). Surgical intervention with split skin graft was performed in 50% of diabetics and 48.7% of nondiabetics. Average length of stay of diabetics was 12.6 days and nondiabetics was 16.2 days (p value: 0.334). Diabetic patients with burns were noted to have higher rate of infection (67% vs 61.8%, p value: 0.803) and mortality (44% vs 35.5%, p value: 0.482). CONCLUSION: The clinical course is different between diabetic and nondiabetic patients with burns injury. Although length of stay and surgical interventions were not significantly different, diabetes as a comorbidity appears to increase the risk of infections and mortality in patients with burns. HOW TO CITE THIS ARTICLE: Vadala R, Princess I, Ebenezer R, Ramakrishnan N, Krishnan G. Burns in Diabetes Mellitus Patients among Indian Population: Does it Differ from the Rest? Indian J Crit Care Med 2020;24(1):11-16.

When attacked by a new enemy, do not forget the old ones. A tale of 2 diseases: tuberculosis and COVID-19.

e two diseases together.

Microbiological Profile of Infections in a Tertiary Care Burns Unit.

BACKGROUND: The burden of infections among burns patients is higher in healthcare settings due to partial or complete loss of skin as a physical barrier among these patients. We intend to present microbiological profile of patients admitted to a tertiary care hospital in South India. AIM: To describe microbiological profile of infections and antimicrobial susceptibility pattern of clinical isolates from burns patients in our tertiary care hospital. MATERIALS AND METHODS: This retrospective analysis was done on consecutive patients admitted with burns over a period of three years at Apollo Specialty Hospitals, a tertiary care facility in Vanagaram, Chennai. Data analysis included clinical isolates from blood, urine, tissue, pus and tracheal aspirate. Types of bloodstream infections, urosepsis and antibiogram are described. RESULTS: Among 219 clinical isolates from various samples, 75% were gram-negative, 19% gram-positive and 6% were yeast like fungi. Among bloodstream infections, 32% were polymicrobial. Urosepsis was observed in 39% patients. Wound infections with sepsis was seen in 39% patients. Gram-negative isolates showed better susceptibility to amikacin, carbapenems, beta lactam - beta lactamase inhibitor combinations. Gram-positive isolates had better susceptibility to macrolides, doxycycline, glycopeptides. CONCLUSION: The high prevalence of gram-negative, polymicrobial infections and multidrug resistant bacteria noted in our patients and the sensitivity patterns would help with appropriate decision on initial antibiotic therapy. However escalation and de-escalation of antibiotics should be planned based on culture reports. HOW TO CITE THIS ARTICLE: Ebenezer R, Princess I, Vadala R, Kumar S, Ramakrishnan N, Krishnan G. Microbiological Profile of Infections in a Tertiary Care Burns Unit. Indian J Crit Care Med 2019;23(9):405-410.