Role of low dose computed tomography on lung cancer detection and mortality - an updated systematic review and meta-analysis.

Chest low dose computed tomography (LDCT) is reported to be a sensitive tool for the detection of lung cancer at asymptomatic stage, thus reducing mortality. The review assesses the effect of LDCT screening on all-cause mortality, lung cancer mortality and incidence rates. We conducted literature searches of PubMed, SCOPUS, and the Cochrane Library from inception through January 2020 to identify relevant studies assessing the diagnostic accuracy of LDCT for lung cancer. We used Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines for reporting this meta-analysis and review. The inclusion criteria were a) Randomized control trials, b) Comparing LDCT to any other form of screening or standard of care, and (c) Primary outcome studied: all-cause mortality, lung cancer-specific mortality, rate of early detection of lung cancer. A total of 11 studies encompassing 97,248 patients were included. When compared with controls (no screening or CXR), LDCT screening was associated with statistically significant reduction in lung cancer mortality (pooled RR 0.86; 95% CI 0.75-0.98); low heterogeneity was observed (I2= 27.86). However, LDCT screening was not associated with statistically significant reduction in all-cause mortality (RR =0.96; 95% CI: 0.92 -1.01). Notably, the LDCT screening was associated with statistically significant increase in lung cancer detection (RR =1.76; 95% CI: 1.14-2.72). LDCT screening has the potential to reduce mortality due to lung cancer among high-risk individuals. LDCT could be considered as a screening modality after careful assessment of other factors like prevalence of TB, proportion of high-risk population, cost, access and availability of LDCT.

Myroides: A Rare but Hard-to-crack Villain in a Critical Care Setup.

How to cite this article: Mahendran AJ, Agrawal S, Rastogi N, et al. Myroides: A Rare but Hard-to-crack Villain in a Critical Care Setup. Indian J Crit Care Med 2021;25(6):735-736.

Neurological manifestations of COVID-19: A brief review.

The COVID-19 pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has been predominantly a respiratory manifestation. Currently, with evolving literature, neurological signs are being increasingly recognized. Studies have reported that SARS-CoV-2 affects all aspects of the nervous system including the central nervous system (CNS), peripheral nervous system (PNS) and the muscular system as well. Not all patients have reverse transcription-polymerase chain reaction positive for the virus in the cerebrospinal fluid, and diagnosing the association of the virus with the myriad of neurological manifestations can be a challenge. It is important that clinicians have a high-index of suspicion for COVID-19 in patients presenting with new-onset neurological symptoms. This will lead to early diagnosis and specific management. Further studies are desired to unravel the varied neurological manifestations, treatment, outcome and long-term sequel in COVID-19 patients.

Emerging prophylaxis strategies against COVID-19.

The Novel corona virus 2019 which started as an outbreak in China in December 2019 has rapidly spread all over the world, such that on 11th March 2020 WHO declared this disease as pandemic. The emergency that the world faces today demands that we develop urgent and effective measures to protect people at high risk of transmission. WHO has accelerated research in diagnostics, vaccines and therapeutics for this novel coronavirus.

Chloroquine in COVID-19: the evidence.

To the Editor The Coronavirus disease 2019 (COVID-19) has been declared as a pandemic by World Health Organisation (WHO). The global mortality has increased, especially in countries like Italy and Iran. With the increasing morbidity and mortality, search for a cure has been the global demand.

Profile of sleep disordered breathing in heart failure with preserved ejection fraction.

Heart failure (HF) with preserved ejection fraction (HFpEF) represents nearly half of HF cases and is increasingly being recognized as a cause of morbidity and mortality. Hypertension (essential or secondary) is an important risk factor of HFpEF, owing to permanent structural changes in heart. A common cause of secondary hypertension is obstructive sleep apnea (OSA). In the present study, we have attempted to seek the frequency and characteristics of sleep disordered breathing (SDB) in HFpEF. Also, we tried to investigate if any correlation exists between the severity of SDB and the severity of diastolic dysfunction. This was a prospective, cross-sectional, case-control study in which 25 case patients with HFpEF and 25 control subjects were included. All the case patients and control subjects went through a detailed clinical, biochemical, echocardiography evaluation and overnight polysomnography. SDB was seen in 64% of the case patients having HFpEF and in 12% of control group with [odds ratio (OR)= 12.2, 95% confidence interval (CI) = 2.83-52.74; p<0.001]. A significant correlation of apnea-hypopnea index (AHI) severity was observed with degree of diastolic dysfunction (r = 0.67; p<0.001). Among HFpEF patients with SDB (16/25), 13 had OSA and only 3 had central sleep apnea (CSA). CSA was present in patients with severe diastolic dysfunction. There were no clinical or sleep quality differences among the OSA and the CSA group. To conclude, a higher frequency of SDB is observed in HFpEF patients. AHI severity correlates with degree of diastolic dysfunction. The underlying mechanisms of correlation between SDB and diastolic dysfunction either through uncontrolled hypertension or direct causation warrant further evaluation.

Clinical and epidemiologic profile of the initial COVID-19 patients at a tertiary care centre in India.

COVID-19 has now become a pandemic. It has spread from Wuhan, China, in December 2019 to a large number of countries within three months. The objective of this work is to report the initial experience with epidemiologic and clinical features, as well as with the management of COVID-19 patients in India. This is a descriptive case series of the first 21 COVID-19 infected patients confirmed with polymerase chain reaction (PCR) and admitted to a tertiary care centre in India from 01.02.2020 to 19.03.2020. Clinical, laboratory, and radiologic data were collected, including age, sex, nationality, travel history, symptoms, duration of stay, and comorbidities. The mean age of the population was 40.3 years with a male preponderance. Thirteen (62%) patients had recent travel history outside India in the previous 30 days, two thirds of whom had travelled to Italy. The most common symptoms were fever and cough (42.9%) followed by sore throat, headache and breathlessness. Vital and laboratory parameters were preserved in all patients and none of them required ventilatory support. Among the first 21 patients diagnosed with COVID-19 infection in India, the typical clinical presentation consisted in a mild upper respiratory tract infection predominantly affecting the young male population. One patient required supplemental oxygen. All patients recovered with no residual symptoms.   *The Safdarjung Hospital COVID 2019 working group: Nitesh Gupta, Sumita Agrawal, Pranav Ish, Suruchi Mishra, Rajni Gaind, Ganapathy Usha, Balvinder Singh, Manas Kamal Sen, Shibdas Chakrabarti (Consultant and Head, Pulmonary Medicine); NK Gupta (Professor, Pulmonary medicine); Dipak Bhattacharya (Consultant, Pulmonary medicine); Rohit Kumar (Assistant Professor, Pulmonary Medicine); Siddharth R. Yadav (Assistant Professor, Pulmonary Medicine); Rushika Saksena (Specialist, Microbiology); Rojaleen Das (Assistant Professor, Microbiology); Vikramjeet Dutta (Assistant Professor, Microbiology); Anupam Kr Anveshi (Senior Resident, Microbiology); Santvana Kohli (Assistant Professor, Anaesthesiology); Naveen KV (Assistant Professor,  Anaesthesiology); Amandeep Jaswal (Assistant Professor, Anaesthesiology).

Evaluation of the clinical profile, laboratory parameters and outcome of two hundred COVID-19 patients from a tertiary centre in India.

COVID-19 is a pandemic with over 5 million cases worldwide. The disease has imposed a huge burden on health resources. Evaluation of clinical and epidemiological profiles of such patients can help in understanding and managing the outbreak more efficiently. This study was a prospective observational analysis of 200 diagnosed COVID-19 patients admitted to a tertiary care center from 20th march to 8th May 2020. All these patients were positive for COVID-19 by an oro-nasopharyngeal swab-rtPCR based testing. Analyses of demographic factors, clinical characteristics, comorbidities, laboratory parameters, and the outcomes were performed. The mean age of the population was 40 years with a slight male predominance (116 patients out of 200, 58%). A majority of the patients (147, 73.5 %) were symptomatic, with fever being the most common symptom (109, 54.5%), followed by cough (91, 45.5%). An older age, presence of symptoms and their duration, leukocytosis, a high quick SOFA score, a high modified SOFA score, need for ventilator support, an AST level more than 3 times the upper limit of normal (ULN), and a serum creatinine level of 2 mg/dl or greater were at a significantly higher risk of ICU admission and mortality. Presence of diabetes mellitus, AST > three times ULN, serum creatinine 2 mg/dl or higher, and a qSOFA score of 1 or higher were all associated with significantly greater odds of critical care requirement. Triage and severity assessment helps in deciding the requirement for a hospital stay and ICU admission for COVID-19 which can easily be done using clinical and laboratory parameters. A mild, moderate and severe category approach with defined criteria and treatment guidelines will help in judicious utilization of health-care resources, especially for developing countries like India.   *Other members of the Safdarjung Hospital COVID-19 working group: Balvinder Singh (Microbiology), MK Sen (Pulmonary Medicine), Shibdas Chakrabarti (Pulmonary Medicine), NK Gupta (Pulmonary medicine), AJ Mahendran (Pulmonary Medicine), Ramesh Meena (Medicine), G Usha (Anaesthesiology), Santvana Kohli (Anaesthesiology), Sahil Diwan (Anaesthesiology), Rushika Saksena (Microbiology), Vikramjeet Dutta (Microbiology), Anupam Kr Anveshi (Microbiology).

Colistin-induced Acquired Bartter-like Syndrome: A Rare Cause of Difficult Weaning.

How to cite this article: Mahendran AJ, Gupta N, Agrawal S, Ish P. Colistin-induced Acquired Bartter-like Syndrome: A Rare Cause of Difficult Weaning. Indian J Crit Care Med 2020;24(8):739-740.

Microscopic polyangiitis in a case of silica exposure: a rare presentation.

A 28-year-old male was admitted for breathlessness, haemoptysis, fever and fatigue. The patient had occupational exposure to silica dust. Arterial blood gas test ABG revealed hypoxemic respiratory failure. Chest CT demonstrated ground glass opacities with interlobular septal thickening and small centrilobular nodules with patchy areas of consolidation in bilateral lungs. He was mechanically ventilated for refractory hypoxemia. The treatment with cyclophosphamide and methylprednisolone lead to recovery and extubation. The final diagnosis was diffuse alveolar haemorrhage due to perinuclear antineutrophil cytoplasmic antibody (ANCA)-associated microscopic polyangiitis (p-ANCA-associated MPA). In a tuberculosis endemic country, for patients presenting with diffuse alveolar haemorrhage (DAH), with history of silica exposure, differential diagnosis of ANCA associated vasculitis must be considered.

Diagnostic utility of endobronchial ultrasound features in differentiating malignant and benign lymph nodes.

Endobronchial ultrasound (EBUS) features have been shown to be useful in predicting etiology of enlarged malignant lymph nodes. However, there is dearth of evidence especially from developing countries. We assessed the EBUS characteristics across various mediastinal and hilar lymphadenopathies. In this prospective study, all patients with mediastinal and hilar lymphadenopathy on CT Chest and who were planned for EBUS-FNA (Fine Needle Aspiration) were included. EBUS features of lymph nodes studied were shape, size, margins, echogenicity, central hilar structure (CHS), coagulation necrosis sign and colour power doppler index (CPDI). These were scored and compared between benign and malignant lymphadenopathies. A total of 86 lymph nodes in 46 patients were prospectively studied of which 23 (26.7%) were malignant, 27 (31.3%) tuberculosis and 36 (41.8%) sarcoidosis. There was significant difference between malignant and benign lymph nodes in terms of CHS [central hilar structutre] (p=0.011), margins (p=0.036) and coagulation necrosis sign (p<0.001). On comparison of features of malignancy and tuberculosis, there were significant differences in margins (p=0.016) and coagulation necrosis sign (p 0.001). However, when malignancy and sarcoidosis was compared, there were differences in echogenicity (p=0.002), CHS (p=0.009) and coagulation necrosis sign (p<0.001). Only coagulation necrosis sign was found to be highly consistent with malignant lymph nodes. The other features cannot be used to distinguish malignant from benign lymph nodes, especially in a developing country like India where tuberculosis is a common cause of mediastinal lymphadenopathy.

Novel technique of performing transbronchial lung cryobiopsy (TBLC) for diagnosing diffuse parenchymal lung diseases (DPLD) in infants.

Childhood interstitial lung disease (ChILD) diagnosis often requires surgical lung biopsy after the common causes are ruled out. However, surgical lung biopsy has its own set of complications. Hence transbronchial lung cryobiopsy has been used in various studies of adult interstitial lung disease (ILD) with good yield and minimal complications. But this newer mode is rarely used in diagnosing children with suspected ILD. Here, we present the first case of the use of this technique in an infant via a rigid tracheoscope.

Sjogren's syndrome presenting with hypokalemic periodic paralysis.

We report a rare case of a 38-year-old female who presented with sudden onset flaccid quadriplegia and respiratory arrest with no significant past clinical history. She was later found to have hypokalemia due to distal renal tubular acidosis and further diagnosed as case of Sjogrens Syndrome.

A systematic review and metanalysis of diagnostic yield of BAL for detection of SARS-CoV-2.

BACKGROUND: The gold standard for diagnosing severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is microbiological confirmation by reverse transcriptase-polymerase chain reaction (RT-PCR)1 most commonly done using oropharyngeal (OP) and nasopharyngeal swabs (NP). But in suspected cases, where these samples are false-negative, bronchoalveolar lavage (BAL) may prove diagnostic. OBJECTIVES: Hence, the diagnostic yield of BAL for detection of SARS-CoV-2 in cases of non-diagnostic upper respiratory tract samples is reviewed. METHODS: Databases such as MEDLINE, Scopus, and Google Scholar were searched using a systematic search strategy. The current study has been in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines and has been registered with the International Prospective Registry of Systematic Reviews (CRD42020224088). RESULTS: 911 records were identified at initial database extraction, of which 317 duplicates were removed and, 596 records were screened for inclusion eligibility. We included total 19 studies in the systematic review, and 17 were included in metanalysis. The pooled estimate of SARS-CoV-2 positivity in BAL was 11% (95%CI: 0.01-0.24). A sensitivity analysis also showed that the results appear to be robust and minimal risk of bias amongst the studies. CONCLUSION: The current study demonstrates that BAL can be used to diagnose additional cases primary disease and superadded infections in patients with severe COVID-19 lower respiratory tract infection.

Evidence-based review of bronchoscopic lung volume reduction.

Emphysema sequentially leads to the loss of gas exchanging surface and an abnormal shape of the diaphragm generating dyspnea refractory to standard medical therapy. Lung volume reduction surgery (LVRS) is a surgical treatment option for patients with severe emphysema whose symptoms are uncontrolled on standard therapy. Bronchoscopic LVR (bLVR) is a process by which lung volume reduction is achieved in a minimally invasive manner using bronchoscopy-guided insertion of valves, coils, sealants, or by thermal vapour ablation like techniques. These therapies have developed over the last few years and have variable results in patients. We have summarized the current evidence available on each of these methods in this review.

Endobronchial ultrasound-guided transbronchial cryo-nodal biopsy: a novel approach for mediastinal lymph node sampling.

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is preferred for evaluating malignant lymph nodes and staging of lung cancer. Nevertheless, larger tissue samples are increasingly needed, particularly for molecular analysis. We describe the feasibility, technical details, and complications of EBUS-guided transbronchial cryo-node biopsy (TBCNB) in four patients with mediastinal adenopathy. The samples obtained by EBUS-TBCNB in all cases were adequate for histopathological examination (HPE) and immunohistochemistry (IHC) staining. In case 1, HPE showed non-caseating epithelioid granuloma with giant cells and fibrosis consistent with sarcoidosis. Case 2 was diagnosed with adenocarcinoma with positivity for ROS1(D4D6). Case 3 showed features of metastatic adenocarcinoma from the breast (positive for Her2, ER, and GATA3). Case 4 was diagnosed with tuberculosis (necrotizing granuloma in histopathology, stain with Ziehl-Neelsen that showed few rod-shaped bacilli). Only one patient had minimal bleeding at the puncture site controlled with cold saline. There were no adverse events such as major bleeding, pneumomediastinum, or pneumothorax.

Vitamin C (ovi) D; An unexplored option!

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Contact tracing: Unearthing key epidemiological features of COVID-19.

COVID-19 is an emerging global pandemic with a steady rise in both morbidity and mortality over the past few months. Contact tracing of COVID-19 patients is an essential task to mitigate the spread. The following case was one of the initial patients reported from India and details the importance of contact tracing, timely testing and adequate quarantine/isolation in disease control.