Role of esophageal manometry in polysomnography of patients with chronic respiratory failure.

Esophageal pressure (Pes) monitoring is performed during polysomnography (PSG) with a thin, water-filled catheter connected to a transducer. The resulting quantitative assessment of respiratory effort can aid in the accurate diagnosis of sleep-related breathing disorders. This was a prospective observational study using Pes in PSG for thirty patients with chronic respiratory failure (CRF) conducted in the Department of Pulmonary, Critical Care and Sleep Medicine at a tertiary care centre of North India. Sleep scoring was done by conventional method and using esophageal manometry and compared polysomnography normal without esophageal manometry recording (PSGN) and polysomnography with esophageal manometry scoring (PSGE). Apnea hypopnea index (AHI) index was similar in both groups. However, respiratory effort related arousals (RERAs) were diagnosed easily using Pes resulting in significant increase in respiratory disturbance index (RDI) and even reclassification in terms of severity of sleep apnea. Besides, Pes was also useful to distinguish obstructive from central hypopnea which cannot be distinguished by routine PSG which can help guide therapy particularly in chronic respiratory failure patients with hypoventilation. Such patients with hypoventilation often require bilevel positive airway pressure as ventilatory support. Central hypopneas and apneas with hypercapnia may require higher-pressure support, a backup rate or even advanced volume assured modes of ventilation. Thus, it can be concluded that Pes in PSG remains a safe and generally well-tolerated procedure. Use of Pes aids to detect RERA and thereby RDI; a better marker of sleep-related breathing disorder rather than AHI. It also helps in differentiating between obstructive and central hypopnea.

Neurocognitive and Quality-of-life Outcomes Following Intensive Care Admission: A Prospective 6-month Follow-up Study.

BACKGROUND: Post-intensive care survivors have decreased quality-of-life scores and prolonged cognitive dysfunction due to baseline factors and events related to intensive care unit admission, which remain largely unrecognized. MATERIALS AND METHODS: A prospective observational cohort study to assess the quality of life and occurrence of cognitive dysfunction, 3 and 6 months following discharge from the intensive care unit, was carried out. We enrolled 136 adults presenting to the intensive care unit with no prior cognitive dysfunction or depression and followed up and assessed them with repeatable battery for the assessment of neuropsychological status (RBANS) and quality of life with short Form-36 (SF-36) health survey. RESULTS: The incidence and prevalence of cognitive dysfunction was 100% at 3 and 6 months, respectively, as assessed by RBANS with a global cognition scores at 3 and 6 months of 71 (IQR 68.5-73) and 74 (IQR 72-86), respectively. Higher Charlson's comorbidity score, increased severity of illness, longer duration of mechanical ventilation, pain, delirium, coma, and hospital stay were associated with statistically significant lower scores at 3 months. The median SF-36 mental component score (MCS) and physical component score (PCS) at 3 months were 38.4 and 32.5 and at 6 months were 38.2 and 32.6, respectively. Poor score was associated significantly with advancing age, poor functional parameters at baseline as evidenced by clinical frailty, poor baseline Katz ADL scores, increased severity of illness, longer duration of mechanical ventilation, occurrence and duration of delirium, coma, pain, and usage of sedatives with or without analgesics. CONCLUSION AND CLINICAL SIGNIFICANCE: Patients discharged from the intensive care unit are at high risk for persistent cognitive impairment and poor quality of life score. Poor baseline patient characteristics and events occurring in ICU are associated with worse cognition and quality of life scores. There is an urgent need to prevent, diagnose, and manage these patients by optimizing intensive care practices. HOW TO CITE THIS ARTICLE: Balasubramanian V, Suri JC, Ish P, Gupta N, Behera D, Gupta P, et al. Neurocognitive and Quality-of-life Outcomes Following Intensive Care Admission: A Prospective 6-month Follow-up Study. Indian J Crit Care Med 2020;24(10):932-937.

Hb Hope: A Rare Variant of Haemoglobin-Forged a Rise in HbA1c on Immunoturbidimetric Assay.

Glycosylated hemoglobin (HbA1c) determination is a powerful means for assessing the evaluation and management of patients with diabetes mellitus. Hemoglobin (Hb) variants and chemically modified derivatives of Hb can affect the accuracy of measurement of HbA1c done by various analytical methods. We report a patient with a rare variant of Hb (Hb Hope) that caused an abnormally high value of HBA1c when assayed using immunoturbidimetric assay ("Tina-quant" 2nd generation assay) and also elucidate the nature of the variant.

Diagnostic and Prognostic Significance of Serum Biomarkers - Serum Amyloid A and CYFRA 21-1 in Lung Cancer.

Introduction: Bronchogenic carcinoma is a leading cause of cancer-related death in men and women. Early diagnosis and treatment in these cases are essential for a better prognosis. Serum biomarkers such as serum amyloid A (SAA) and CYFRA 21-1 have generated encouraging results regarding their use in the diagnosis of these cases but data on their role in the Indian scenario are still lacking. Aim: The study aims to measure the levels of SAA and CYFRA 21-1 in various types of lung cancer and compare them with patients without lung cancer. It also aims to compare the values of these biomarkers before and after chemotherapy and correlate them with response to treatment. Materials and Methods: It was a prospective, case-control study conducted in the Department of Pulmonary Medicine, Government Medical College, Chandigarh. All histologically and/or cytologically proven lung cancer cases were included in the study group while patients with diseases other than lung cancer formed the control group. All patients were evaluated through a complete history and thorough clinical examination. Measurement of SAA and CYFRA 21-1 in blood was done by sandwich ELISA method. The patients in the study group were followed up regularly and the biomarkers were measured again after four cycles of chemotherapy. The response of tumors to chemotherapy was evaluated as per modified Response Evaluation Criteria in Solid Tumors criteria. The statistical analysis was carried out using SPSS version 19.0. Results: The study group and control group included 20 patients each. Hoarseness of voice and hemoptysis were significantly associated with lung cancer patients (P = 0.001 and P = 0.025, respectively). Serum levels above 8745 ng/ml for SAA and 2.55 ng/ml for serum CYFRA 21-1 were used as diagnostic biomarker in lung cancer. The serum levels of CYFRA 21-1 were found to be significantly raised in nonsmall cell carcinoma (NSCLC) in comparison to SCLC of lung. There was a statistically significant decrease in the serum levels of CYFRA 21-1 in lung cancer patients on C4 cycle of chemotherapy in comparison to C1 cycle (P = 0.014). Conclusion: SAA and CYFRA 21-1 could be valuable diagnostic biomarkers in lung cancer. CYFRA 21-1, in addition, could also be used as prognostic biomarker in lung cancer patients undergoing chemotherapy as it showed significant decrease after C4-cycle of chemotherapy. It can also be a potential biomarker to differentiate small cell and NSCLC.

Determination of sputum eosinophil count and serum absolute eosinophil count in patients with bronchial asthma and its correlation with disease severity and response to treatment.

Background: Sputum eosinophils can be used to assess severity of disease and response to treatment in bronchial asthma. Eosinophilic inflammation in the airways can also be marked by blood eosinophilia. In this study, we tried to determine the sputum eosinophil count and serum absolute eosinophil count in patients with asthma and correlate them with disease severity and treatment response. Materials and Methods: It was a cross-sectional intervention study including all consecutive cases with a diagnosis of bronchial asthma based on spirometry and clinical history. An induced sputum sample and blood were sent for eosinophil count to the laboratory. All the patients were started on inhaled corticosteroids and followed up at the end of 1 month with spirometry, sputum eosinophil count and AEC. Statistical Package for the Social Sciences for Windows v20.0 (IBM SPSS Corp.; Armonk, NY, USA) was used for statistical analysis. Results: There was no significant difference in the mean sputum eosinophil count (%) in mild, moderate and severe disease (f = 0.24; P = 0.79) or in AEC (f = 1.48; P = 0.24). At follow-up, all patients with moderate and severe disease showed significant improvement in FEV1 (P = 0.0001). The mean sputum eosinophil count and AEC (%) in the three subgroups was also seen to decrease at the end of the follow-up period (f = 0.08; P = 0.9 and f = 2.75; P = 0.07, respectively). Conclusion: Sputum eosinophils and AEC are important markers of airway inflammation. All our patients showed improvement in FEV1, sputum eosinophil count and AEC after 1 month of treatment thus confirming the role of ICS in the treatment of eosinophilic asthma.

Persistent pneumothorax with bronchopleural fistula in COVID lung - An emerging challenge.

Bronchopleural fistula (BPF) is an uncommon entity in patients with coronavirus disease 2019 (COVID-19). It may arise due to various causes ranging from the disease itself to complications of treatment. If left untreated, it may increase the morbidity, hospital stay, and adversely affect the outcome. We hereby present a series of cases with a persistent pneumothorax and associated BPF due to varying etiologies. While three of our cases developed a pneumothorax while on non-invasive ventilation, other three were on oxygen therapy. One patient developed a spontaneous pyopneumothorax and septicemia and succumbed to the complications. Another patient on non-invasive ventilation died due to complications of pregnancy. The management of each case varied depending on their clinical presentation.

Nintedanib vs pirfenidone in the management of COVID-19 lung fibrosis: A single-centre study.

BACKGROUND: COVID-19 pneumonia is complicated with residual lung fibrosis, as evidenced by imaging and postmortem pathological findings. In addition to steroids, we compared the efficacy of nintedanib and pirfenidone in the management of COVID-19 lung fibrosis measured by CT severity score (CTSS). METHODS: All cases of COVID-19 pneumonia diagnosed as COVID-19 positive by RT-PCR having SpO2 ⩽ 96% and CTSS ⩾ 10 even after 15 days were included in the study. The patients were divided into three groups. All three groups received steroids at a dose of 1 mg/kg body weight of prednisolone or equivalent. The first group received steroids alone, the second group received pirfenidone with steroids and the third group received nintedanib with steroids. All patients were followed up at 6 and 12 weeks. The primary endpoint of our study was to find out any improvement in CTSS. RESULTS: Out of 90 patients, 56 patients completed the study. Among three groups, 19 (33.9%) patients received steroids (control) only, 16 (28.6%) patients received steroids with pirfenidone and 21 (37.5%) patients received steroids with nintedanib. The study population had a mean (±SD) age of 52.5 ± 10.1 years, mean (±SD) C-reactive protein of 97.1 ± 102.2 mg/L (normal <6 mg/L), mean (±SD) serum ferritin 459.4 ± 305.5 ng/mL (normal <250 ng/mL), mean (±SD) serum d-dimer level 2.1 ± 2.6 µg/mL (normal <0.5 µg/mL) and mean (±SD) CTSS of 16.9 ± 4.3. There was significant improvement in CTSS in group receiving nintedanib compared to pirfenidone at 12 weeks (3.67 ± 1.21 vs 9.07 ± 1.12) with a p-value <0.01. CONCLUSION: Along with steroids in the treatment of COVID-19 lung fibrosis, there was a significant improvement in lung CTSS with nintedanib compared to pirfenidone.

Supervised hospital based pulmonary rehabilitation outcome in long COVID-experience from a tertiary care hospital.

Introduction: Some patients suffer from various multisystem symptoms even after active process of COVID-19 illness has settled lasting more than four weeks called as long COVID. Pulmonary rehabilitation therapy is the proposed option in those patients. This study aims to study the impact of pulmonary rehabilitation on outcome of long COVID patients through improvement in mMRC dyspnea scale, oxygen saturation, cough score, six-minute walk distance and biomarkers of inflammation. Materials and Methods: A retrospective observational study was carried out from the data of electronic medical records among 71 Long COVID patients. Parameters like Spo2, MMRC scale, cough score, six-minute walking distance along with blood levels of D-dimer, C-reactive protein (CRP), leucocyte count at the time of admission and after three weeks of pulmonary rehabilitation were collected. The outcome among the patients was divided into full recovery and partial recovery group. Statistical analysis was done using SPSS software version 19.0. Result: Among 71 cases in our study 60 (84.50%) where male with mean age was 52.7 ± 13.23 years. Biomarkers like CRP and d-Dimer were elevated in 68 (95.7%) and 48 (67.6%) patients, respectively, at the time of admission. After 3 weeks of pulmonary rehabilitation mean SPO2, cough score, 6MWD showed significant improvement and normalization of biomarkers in recovered group of 61 out of 71 which was statistically significant. Conclusion: Significant improvement of oxygen saturation, mMRC grade, cough score, six-minute walk distance and normalization of biomarkers were marked following pulmonary rehabilitation. Thus, pulmonary rehabilitation therapy should be offered to all long COVID cases.

Recent progress in development of 2,3-diaminomaleonitrile (DAMN) based chemosensors for sensing of ionic and reactive oxygen species.

2,3-Diaminomaleonitrile (DAMN) has proved to be a valuable organic π-conjugated molecule having many applications in the area of chemosensors for sensing of ionic and neutral species because of its ability to act as a building block for well-defined molecular architectures and scaffolds for preorganised arrays of functionality. In this article, we discussed the utilization of 2,3-diaminomaleonitrile (DAMN) for the design and development of chemosensor molecules and their application in the area of metal ion, anion and reactive oxygen species sensing. Along with these, we present different examples of DAMN based chemosensors for multiple ion sensing. We also discuss the ion sensing mechanism and potential uses in other related areas of research.