Status of Serum Calcium in Patients with Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) remains a major public health problem with relatively high prevalence rates worldwide (5-13%). COPD is a major cause of morbidity and mortality worldwide and results in an economic and social burden that is both substantial and increasing. The purpose of the study was to explore the alteration of serum calcium in patients with COPD. This cross-sectional study was carried out in the Department of Biochemistry, Mymensingh Medical College, Bangladesh from January 2021 to December 2021. Data was collected from Medicine Department of Mymensingh Medical College Hospital, Mymensingh. A total number of 120 subjects participated in this study. Out of them, 60 apparently normal healthy individuals were selected as Group I and another 60 diagnosed COPD patients were selected as Group II. Serum calcium was measured by colorimetric method using the test kit. The results were calculated and analyzed by using statistical package for social science (SPSS), windows package version 21.0. Data were expressed in mean ±SD and statistical significance was done by Student's unpaired 't' test. In this study, the mean ±SD values of serum calcium were 9.21±1.06mg/dl and 8.26±0.95mg/dl in Group I and Group II respectively. The results were highly significant (p<0.001). The result suggested that there was significant relation between COPD and alteration of serum calcium. So, by this study we recommended that routine evaluation of serum calcium is important for prevention of exacerbations, reduction of morbidity and mortality in patients with COPD.

An Unusual Etiology of Fluorodeoxyglucose Avid Intrathoracic Lymph Nodes

A middle-aged man in his 50s, active smoker, presented to the pulmonary office for lung cancer evaluation. On a low-dose computed tomography for lung cancer screening, he was found to have an 8 mm endobronchial lesion in the right main stem bronchus. A PET-CT revealed no endobronchial lesion, but incidentally, fluorodeoxyglucose (FDG) avidity was present in the right hilar (SUV 13.2) and paratracheal lymph nodes (LNs). He underwent bronchoscopy and EBUS-TBNA of station 7 and 10 R LNs. The fine needle aspiration (FNA) revealed necrotizing epithelioid granuloma. The acid-fast bacilli (AFB) and Grocott methenamine silver (GMS) stains were negative. He had suffered from pneumonic tularemia 13 months ago and immunohistochemical staining for Francisella tularensis on FNA samples at Center for Disease Control and Prevention was negative. The intense positron emission tomography (PET) avidity was attributed to prior tularemic intrathoracic lymphadenitis without active tularemia, a rare occurrence. To the best of our knowledge, PET-positive intrathoracic lymph node beyond one year without evidence of active tularemia has not been previously reported.

Status of Serum Magnesium and Uric Acid in Patients with Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) remains a major public health problem with relatively high prevalence rates worldwide (5.0-13.0%). COPD is a major cause of morbidity and mortality worldwide and results in an economic and social burden that is both substantial and increasing. The purpose of the study was to explore the relationship of biochemical alterations of serum magnesium and uric acid with frequent exacerbations, hypoxia, increase hospital stay, morbidity and mortality in patients with COPD. This cross-sectional study was carried out in the Department of Biochemistry, Mymensingh Medical College, Bangladesh from January 2021 to December 2021. Data was collected from Medicine Department of Mymensingh Medical College Hospital, Bangladesh. A total number of 120 subjects participated in this study. Out of them, 60 apparently normal healthy individuals were selected as Group I and another 60 diagnosed COPD patients were selected as Group II. The results were calculated and analyzed by using statistical package for social science (SPSS), windows package version 21.0. Serum magnesium was measured by photoelectric colorimetric method using the test kit and serum uric acid was measured by enzymatic colorimetric method using the test kit. Data were expressed in mean±SD and statistical significance of different parameter was done by Pearson's correlation co-efficient test. The mean±SD values of serum magnesium were 2.15±0.29mg/dl and 1.54±0.30mg/dl in Group I and Group II respectively. Result was statistically highly significant (p<0.001). The mean±SD values of serum uric acid were 5.43±2.05mg/dl and 6.86±1.61mg/dl in Group I and Group II respectively. Result was statistically highly significant (p<0.001). Pearson's correlation coefficient test showed that there was significant (p=0.001) negative correlation (r= -0.415) found between serum magnesium and serum uric acid in study group. In this study, the result suggested that there was significant relation between COPD exacerbations and alteration of these biochemical parameters. So, by this study we recommended that routine evaluation of these parameters is important for prevention of exacerbations, reduction of morbidity and mortality in patients with COPD.

A 52-Year-Old Woman With a History of Ulcerative Colitis and New Onset Severe Dyspnea

CASE PRESENTATION

A 52-year-old woman was referred to the pulmonary office for evaluation of worsening dyspnea in August 2022. She had been diagnosed with asthma 22 years ago after she experienced chronic cough, sputum production, occasional wheezing, and mild exertional shortness of breath. Over the years, she was treated with different inhalers and was currently on triple inhaler therapy. A pulmonary function test in 2020 was normal. She had a history of ulcerative colitis and underwent a total colectomy in 1998. In the early 2000s, the patient also experienced episcleritis. Her other medical conditions included hyperlipidemia, gout, and gastroesophageal reflux disease.

The Role of Surgery in Stage I Small Cell Lung Cancer: A National VA Database Analysis

BACKGROUND

Historically, limited stage Small Cell Lung Cancer (SCLC) has been treated with concurrent chemoradiation (CRT). While current NCCN guidelines recommend consideration of lobectomy in node-negative cT1-T2 SCLC, data regarding the role of surgery in very limited SCLC is lacking.

METHODS

Data from the National VA Cancer Cube were compiled. A total of 1,028 patients with pathologically confirmed stage I SCLC were studied. Only 661 patients that either received surgery or CRT were included. Interval-censored Weibull and Cox proportional hazard regression models were used to estimate median overall survival (OS) and hazard ratio (HR), respectively. Two survival curves were compared by a Wald test. Subset analysis was performed based on the location of the tumor in the upper vs. lower lobe as delineated by ICD-10 codes C34.1 and C34.3.

RESULTS

Four-hundred and forty-six patients received concurrent CRT; while 223 underwent treatment that contained surgery (93 surgery only, 87 surgery/chemo, 39 surgery/chemo/radiation and 4 surgery/radiation). The median OS for the surgery-inclusive treatment was 3.87 years (95% CI 3.21-4.48) while median OS for the CRT cohort was 2.45 years (95% CI 2.17-2.74). HR of death for surgery-inclusive treatment when compared to CRT is 0.67 (95% CI 0.55-0.81; P < .001). Subset analysis based on the location of the tumor in both the upper or lower lobes showed improved survival with surgery as compared to CRT regardless of the location. HR for the upper lobe was 0.63 (95% CI 0.50-0.80; P < .001) and lower lobe 0.61 (95% CI 0.42-0.87; P = .006). Multivariable regression analysis accounting for age and ECOG-PS shows a HR 0.60 (95% CI 0.43-0.83; P = .002) favoring surgery.

CONCLUSIONS

Surgery was used in less than a third of patients with stage I SCLC who received treatment. Surgery-inclusive multimodality treatment was associated with a longer overall survival as compared to chemoradiation, independent of age, performance status or tumor location. Our study suggests a more expansive role for surgery in stage I SCLC.

Study on Blood Pressure Profile in School Children of Mymensingh City

High blood pressure and its related problems are progressively assuming public health dimensions in developing countries like Bangladesh. There was a suggestion that hypertensive process can be aborted in its early stages. But it is poorly understood in its early stages. So, early natural history of hypertension and its evolution from the youth needs to be investigated. Objective of this study was to determine blood pressure distribution in school children aged 6-15 years. This descriptive cross-sectional study was conducted in the Department of Paediatrics, Mymensingh Medical College, Mymensingh, Bangladesh from November 2014 to October 2015. The sample was collected by simple random sampling from five different schools of Mymensingh after applying inclusion and exclusion criteria. After taking proper history and doing relevant examination, both systolic and diastolic BP was recorded by auscultatory method. Out of 994 children, 480(48.29%) were boys and 514(51.71%) were girls. In boys, the mean±SD of systolic and diastolic blood pressure (BP) were 105.9±10.8 mm of Hg and 67.4±6.7 mm of Hg and in girls it was 106.1±11.8 and 67.5±6.9 mm of Hg respectively. Systolic BP was found higher in girls belongs to 10-13 years. The study has shown that BP rises linearly with age and both systolic and diastolic BP has a significant positive correlation with age, sex, height and BMI in both sexes. This study also showed, 46(4.6%) children were hypertensive and 89(8.9%) were pre-hypertensive. Hypertension was found more in girls but there was no significant difference between two sexes. Hypertension was found more in relation to overweight, obesity and family history of hypertension. Hypertension is not uncommon in children. Routine blood pressure measurement should be conducted in all children.

Evaluation of Fecal Pancreatic Elastase-1 as a Measure of Pancreatic Exocrine Function in Children with Pancreatitis

Pancreatic exocrine insufficiency occurs as a clinical consequence of chronic pancreatitis leading to fat maldigestion, malabsorption and malnutrition. Fecal elastase-1 is a laboratory-based test used for the diagnosis or exclusion of pancreatic exocrine insufficiency. The aim of the study was to observe the value of fecal elastase-1 in children with pancreatitis as an indicator of pancreatic exocrine insufficiency. This was a cross-sectional descriptive study conducted from January 2017 through June 2018. Thirty children with pain abdomen as control and 36 patients with pancreatitis as cases were included. An ELISA technique which recognizes human pancreatic elastase-1 from spot stool sample was employed for the test. Fecal elastase-1 activity in spot stool samples in acute pancreatitis (AP) ranged from 198.2-500μg/g with a mean of 342.1±136.4μg/g, acute recurrent pancreatitis (ARP) ranged from 15-500μg/g with a mean of 332.8±194.5μg/g and chronic pancreatitis (CP) ranged from 15-492.8μg/g with a mean of 222.2±197.1μg/g was obtained. In controls, fecal elastase-1 ranged from 28.4-500μg/g with a mean of 398.8±114.9μg/g. Disease severity was classified as mild to moderate pancreatic insufficiency (fecal elastase-1 100 to 200μg/g stool) was found in AP (14.3%) and CP (6.7%) cases. The severe pancreatic insufficiency (fecal elastase-1<100μg/g stool) was observed in ARP (28.6%) and CP (46.7%) cases. Malnutrition was observed in severe pancreatic insufficiency cases. This study result showed that fecal elastase-1 can be used as a measure of pancreatic exocrine function in children with pancreatitis.

A 52-Year-Old Man Who Smokes With Rapidly Progressive Respiratory Failure

CASE PRESENTATION

A 52-year-old White man, who currently smokes, was admitted to the medical ICU with worsening shortness of breath. The patient was dyspneic for a month and had been clinically diagnosed with COPD by his primary care doctor and started on bronchodilators and supplemental oxygen. He had no known medical history or recent illness. His dyspnea worsened rapidly over the next month, prompting admission to the medical ICU. He was on high-flow oxygen followed by noninvasive positive pressure ventilation and then mechanical ventilation. He denied cough, fever, night sweats, or weight loss at the time of admission. There was no history of work-related or occupational exposures, drug intake, or recent travel. Review of systems was negative for arthralgia, myalgia, or skin rash.

A Woman With Progressive Dyspnea and Seronegative Rheumatoid Arthritis

CASE PRESENTATION

A 66-year-old woman with a medical history of seronegative rheumatoid arthritis on long-standing methotrexate and adalimumab therapy was referred to the pulmonary clinic for abnormal chest imaging. The patient was also under evaluation by rheumatology physicians for increased fatigue, nonproductive cough, and recurrent sinus infections. At the time of the initial pulmonary visit, the patient complained of acute onset of bilateral blurry vision and subsequently was diagnosed with anterior uveitis and received ophthalmic steroids with significant improvement. The patient's biologic therapy was discontinued because of a concern for possible drug toxicity. Over the course of 4 months, the patient experienced worsening dyspnea with exertion. She was a lifelong nonsmoker and had no history of recent travel. However, on review of possible environmental exposures, patient stated using feather pillows and bedding for several decades.

Updates in idiopathic pulmonary hemosiderosis in 2022: A state of the art review

This manuscript reports the recent advances in idiopathic pulmonary hemosiderosis (IPH), a rare cause of diffuse alveolar hemorrhage in children and adults. This narrative review of the literature summarizes different aspects of IPH, including proposed pathogenesis, patient demographics, clinical and radiological characteristics, treatment, and prognosis. Additionally, the association between Celiac Disease (CD) and IPH is carefully evaluated. IPH is a frequently misdiagnosed disease. The delay in the diagnosis of IPH is often significant but fortunately, appears to have decreased in recent years. IPH in adults and children have distinct demographic preferences. The autoantibodies are common in IPH but with a definite difference between the adult and pediatric populations. The definitive diagnosis of IPH requires lung biopsy and careful exclusion of all competing diagnoses, even with lung biopsy showing bland pulmonary hemorrhage. The presence of nonspecific inflammatory cells or lymphoid aggregates may suggest a secondary immunologic phenomenon and needs careful evaluation and follow-up. A substantial number of patients suffer from coexisting CD, also known as Lane-Hamilton syndrome (LHS), and all patients with IPH need to be evaluated for LHS by serology. Although strict gluten free diet can manage the majority of patients with LHS, other patients generally require immunosuppressive therapy. The corticosteroids are the backbone of IPH therapy. Recently utilized experimental treatment options include mesenchymal stem cell transplant, liposteroid and bronchial artery embolization. The immunosuppression should be adjusted to achieve optimal disease control. Patients may progress to end-stage lung disease despite all measures, and lung transplantation may be the only viable option.

Procalcitonin versus C-Reactive Protein as a Biomarker for Prediction of Bacterial Infection in Children with Febrile Neutropenia in Acute Leukemia

Febrile neutropenia (FN) is a frequently occurring treatment-related complication with significant morbidity and mortality for childhood acute leukemia. Early diagnosis and assessment of severity are essential steps for early comprehensive treatment to reduce FN-related morbidity and mortality. Biomarkers like C-reactive protein (CRP) and procalcitonin (PCT) can be used to assess and predict the bacterial infection in children with febrile neutropenia. The objective of the study was to determine the role of procalcitonin and CRP as a biomarker for prediction of bacterial infection in children with FN in acute leukemia. This prospective observational study was conducted in the Department of Pediatric Hematology and Oncology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Bangladesh from August 2020 to July 2021. Total 58 Children with acute leukemia aged 1 to <18 years with FN were analyzed in this study. A proper history and thorough physical examination were carried out. The blood sample was sent for biomarkers (Procalcitonin and CRP) within 24 hours of the onset of FN and other investigations, such as Complete blood count, Blood C/S, Urine R/E and C/S. Metabolic workup (SGPT, Serum Creatinine, Serum Electrolytes, Serum Ca+) was also done in every patient. Stool R/E & C/S, Chest X-ray, Wound swab for C/S were done when the patient presented with diarrhoea, cough, respiratory distress and focal sepsis respectively. In this study, the mean age of the patients was 6.62±4.07 years (1.10-16.0 years) and 34 patients (58.6%) were male. In 65.5% of patients, localizing signs of infection were not identified. Of the 58 patients, 12 patients (20.7%) showed positive blood culture and 2 patients (3.4%) showed positive urine culture. Klebsiella spp (41.0%) was the most frequent organism isolated followed by Acinetobacter (17.0%), Pseudomonas (17.0%) and E. coli (17.0%). The median PCT levels were significantly higher in patients with bacterial infection than patients without bacteremia (26.10μg/l versus 0.78μg/l, p=0.002) and PCT level >2μg/l was significantly associated with bacteremia. The median CRP levels in the bacteremia and without-bacteremia patients were 137.4mg/L and 54.17mg/L, respectively (p=0.036). In direct comparisons, PCT showed better overall performance than CRP with the AUC being 0.797 (95% CI 0.651-0.943) for PCT and 0.697 (95% CI 0.54-0.855) for CRP in predicting the bacterial infection. PCT and CRP both are useful biomarkers for the prediction of bacteremia, but PCT may be a superior early biomarker as compared to CRP to predict bacterial infection in children with febrile neutropenia in acute leukemia.

Vaping Associated Acute Eosinophilic Pneumonia: A Clinical and Radiologic Mimicker of COVID-19

Acute eosinophilic pneumonia (AEP) is a rare cause of respiratory failure. It is primarily a disease of smokers, either a new smoker or an existing one with a recent increase in cigarette consumption. Other risk factors include toxic gas exposure, inhalational illicit drugs, and smoking marijuana. AEP has also been reported in patients with e-cigarette or vaping associated lung injury (EVALI). We present the case of a 20-year-old male who presented to the hospital with acute respiratory failure. The patient has been vaping heavily for the past three months and started smoking three days before presenting to the emergency department. He was hypertensive, tachycardic, tachypneic, and required high-flow nasal cannula to maintain SpO2 > 92%. His condition deteriorated in the first 24 hours following hospitalization requiring noninvasive positive pressure ventilation. Bronchoalveolar lavage revealed an eosinophil count of 36%. Bronchoalveolar lavage (BAL) cytology revealed lipid-laden macrophages. He was diagnosed with AEP due to EVALI, and the patient was treated with high dose corticosteroid with subsequent improvement. Before the bronchoscopic evaluation, the clinical and radiologic findings were consistent with COVID-19, and the patient was tested twice for SARS-CoV-2 PCR. In the appropriate clinical setting, AEP should be considered in the differential diagnoses of community-acquired pneumonia, acute respiratory distress syndrome (ARDS), and COVID-19, especially in this pandemic era.

Comparison of Carboplatin With Cisplatin in Small Cell Lung Cancer in US Veterans

IMPORTANCE

The current standard of care for the treatment of small cell lung cancer (SCLC) is concurrent chemoradiation for patients with limited-stage SCLC (LS-SCLC) and chemoimmunotherapy for extensive-stage SCLC (ES-SCLC). The backbone of chemotherapy regimens in both is a platinum-etoposide doublet: cisplatin is traditionally the preferred platinum agent in the curative intent setting, whereas carboplatin is preferred in ES-SCLC because of its favorable toxicity profile.

OBJECTIVE

To determine whether cisplatin is associated with better survival outcomes than carboplatin in treating LS-SCLC and ES-SCLC.

DESIGN, SETTING, AND PARTICIPANTS

In this cohort study, data were compiled from the National Veterans Affairs Central Cancer Registry for patients with SCLC who received platinum-based multiagent chemotherapy between 2000 and 2020 for ES-SCLC and 2000 and 2021 for LS-SCLC. Only patients with pathologically confirmed cases of LS-SCLC who received concurrent chemoradiation and ES-SCLC who received chemotherapy were included.

MAIN OUTCOMES AND MEASURES

The primary end point was overall survival (OS). The secondary end points included OS by Eastern Cooperative Oncology Group performance status, age, and laterality. Interval-censored Weibull and Cox proportional hazard regression models were used to estimate median OS and hazard ratios (HRs), respectively. Survival curves were compared by a Wald test.

RESULTS

A total of 4408 SCLC cases were studied. Most patients were White (3589 patients [81.4%]), male (4252 [96.5%]), and non-Hispanic (4142 [94.0%]); 2262 patients (51.3%) were 60 to 69 years old, followed by 1476 patients (33.5%) aged 70 years or older, 631 patients (14.3%) aged 50 to 59 years, and 39 patients (0.9%) aged 30 to 49 years. Among 2652 patients with ES-SCLC, 2032 were treated with carboplatin-based therapy and 660 received cisplatin; the median OS was 8.45 months (95% CI, 7.75-9.20 months) for cisplatin and 8.51 months (95% CI, 8.07-8.97 months) for carboplatin (HR, 1.01; 95% CI, 0.91-1.12; P = .90). Subset analysis showed no survival difference between the 2 agents in different age or performance status groups except for patients aged 70 years and older, for whom the median OS was 6.36 months (95% CI, 5.31-7.56 months) for cisplatin and 8.47 months (95% CI, 7.79-9.19 months) for carboplatin (HR, 0.77; 95% CI, 0.61-0.96; P = .02). Multivariable analysis of performance status and age did not show a significant difference in survival between the 2 groups (HR, 0.96; 95% CI, 0.83-1.10; P = .54). Of 1756 patients with LS-SCLC, 801 received carboplatin, and 1018 received cisplatin. The median OS was 26.92 months (95% CI, 25.03-28.81 months) for cisplatin and 25.58 months (95% CI, 23.64-27.72 months) for carboplatin (HR, 1.04; 95% CI, 0.94-1.16; P = .46). The median OS was not significantly different between 2 agents according to cancer stage (I-III), performance status, and age groups. A multivariable analysis of factors associated with OS accounting for stage (I-III), performance status, and age did not demonstrate a significant difference in survival between carboplatin and cisplatin in patients with LS-SCLC (HR, 0.995; 95% CI, 0.86-1.15; P = .95).

CONCLUSIONS AND RELEVANCE

Cisplatin is not associated with a survival advantage over carboplatin among patients with either ES-SCLC or LS-SCLC, irrespective of performance status and age. The favorable toxicity profile of carboplatin and comparable OS support its use in both LS-SCLC and ES-SCLC in clinical practice and may allow more room for combination with novel treatment strategies in clinical trials.

Comparison of Growth of School Children in Mymensingh City Area, Bangladesh Using the 2000 CDC Standards and 2007 WHO Standards

Growth assessment is an essential component of child health surveillance. The most influential tool in the growth assessment is the growth chart. Growth parameters of children are usually interpreted in relation to international standards like the NCHS/1977, CDC/2000 and WHO/2007 growth charts. This comparative study was carried out in the Department of Paediatrics, Mymensingh Medical College, Mymensingh, Bangladesh from November 2014 to October 2015 to compare the growth parameters of children using 2000 CDC standards and 2007 WHO standards. A total of five hundred healthy school children, aged 6 to 10 years were randomly selected proportionately from each class of five government primary schools from Mymensingh city area. Children with physical deformities and acutely ill and those with chronic debilitating diseases were excluded from the study. The mean and median weight, height and BMI were calculated for each age and sex. The median weight, height and BMI were then standardized by converting them to Z-scores (SD) for comparing against known reference values of 2000 CDC and 2007 WHO charts. Among 500 children, 252(50.4%) were boys and 248(49.6%) were girls. The mean age was found 8.0±1.42 years in boys and 8.04±1.42 years in girls. The mean weight was found 24.4±6.36kg in boys and 24.08±6.35kg in girls. The mean height was 125.90±10.16cm in boys and 125.38±10.74cm in girls. The mean weight, height and BMI of boys and girls were found to be lower in all age groups with compared to 2000 CDC standard and 2007 WHO standard but were closer to the WHO standards compared to the CDC standards. According to CDC and WHO in the study it was observed that underweight was found 16.3% and 14.7%, stunting 7.1% and 6.7%, overweight 6.7% and 8.7%, and obese 2.8% and 4.0% respectively in male subjects. On the other hand, in female subjects it was observed that according to CDC chart and WHO chart underweight was found 19.4% and 13.3%, stunting 6.0% and 4.8%, overweight 7.3% and 8.1% and obese 2.0% and 2.0% respectively. The findings in this study imply that growth pattern of Bangladeshi school children is closer with WHO standards and wider from CDC standards.

Clinical Profile and Immediate Outcome of Pyogenic Meningitis in Children

Meningitis literally means inflammation of the meninges. It is mostly caused by bacteria, virus, fungus and protozoa and pyogenic meningitis constitutes a serious neurological disorder associated with significant morbidity and mortality in developing countries. This study was carried out to evaluate the clinical presentation and immediate outcome of pyogenic meningitis in children. This was a prospective observational study and conducted at department of Paeditrics in Cumilla Medical College Hospital, Cumilla, Bangladesh from July 2014 to June 2015. Total 50 children were diagnosed as pyogenic meningitis fulfilling the inclusion criteria was included in this study. Cases were enrolled purposively. Immediately after admission through history and clinical examination, complete blood count, random blood sugar, Cerebrospinal fluid (CSF) examination and blood culture was done in all patients. For statistical analysis chi-square test was done and significance of analysis was made when p value <0.05. This study includes patients aged between 2 months to 12 years and male female ratio was 1.5:1. Several risk factors like male sex (60.0%), age below one year (42.0%), Protein energy malnutrition (PEM) (30.0%), not exclusively breastfed (44.0%) were identified. Common presenting complaints were fever (100.0%), convulsion (96.0%), altered consciousness (42.0%) and vomiting (38.0%). Common physical signs were neck rigidity (56.0%), Kernig's sign (26.0%) and bulged fontanelle (34.0%). CSF was hazy in 54.0%, clear in 38.0% and turbid in 08.0% cases, CSF protein was more than 100mg/dl in 90.0% of the cases and glucose was less than 40mg/dl in most of the cases (94.0%). Streptococcus Pneumoniae (49.0%) followed by Neisseria Meningitidis (38.0%) were the two most commonly isolated organism responsible for pyogenic meningitis. Mortality rate during hospital stay was 18.0% and complications developed in 18.0% of cases. To avoid maltreatment in our resource limited setting due to failure of identifying organism, this study might help to administer appropriate antibiotics against organism and to reduce morbidity and mortality in meningitis. This study revealed less mortality rate in our country than neighbors and severe malnutrition important risk factors for the burden of pyogenic meningitis. It requires large scale multicentre studies to establish the whole scenario of Bangladesh.

Comparative Study between Acacia Nilotica versus Povidone Iodine in Topical Treatment of Omphalocele Major

Well established and common practice in conservative management of omphalocele major is escharotics therapy with different topical agents. Among them mercurochrome, alcohol, silver salts, povidone iodine, acacia nilotca paste are commonly used. It is a comparative study between application of acacia nilotica paste and povidone iodine solution as a primary non surgical treatment of omphalocele major regarding efficacy and safety of these two topical agents. A double blind randomized controlled study was conducted at the department of Paediatric Surgery, Mymensingh Medical College Hospital, Mymensingh, Bangladesh from July 2016 to June 2019. In this study 20 cases of omphalocele major and randomly divided into two equal groups. Group A and Group B treated with acacia nilotica paste and povidone iodine solution respectively. Gastroschisis, ruptured-omphalocele major or omphalocele minor excluded in this study. The size of the fascial defect in cm, time required for full oral feeding tolerance and duration of hospital stay were evaluating parameters. Patients with Group A tolerated full oral feeding earlier, shorter total hospital stay duration and low mortality rate than those from Group B. Application of acacia nilotica is a safe and effective treatment of omphalocele major regarding rapid full oral feeding tolerance, shorter hospital stay and low mortality rate.

Solitary Rectal Ulcer Syndrome: A Rare and Often Misdiagnosed Cause of Rectal Bleeding in Children

Solitary rectal ulcer syndrome (SRUS) is an uncommon benign rectal disorder. Typically, young adults are affected and it is rare in children. Straining during defecation, self-induced trauma and paradoxical contraction of puborectalis muscle are the major contributing factors of this condition. Clinical features of SRUS are rectal bleeding, mucorrhoea, excessive straining during defecation, tenesmus, feeling of incomplete defecation and constipation. A complete and thorough history is most important for diagnosis of SRUS. Rectal bleeding may be misinterpreted as originating from an anal fissure caused by constipation or as other causes of rectal bleeding such as a juvenile polyp. The best and most accurate diagnostic method of SRUS is rectal biopsy. The major histological feature of SRUS is fibromuscular obliteration of the lamina propria. Avoiding straining, regular toilet habit, use of bulk laxatives, steroid and sucralfate enemas are the mainstay of treatment. Biofeedback mechanism is another treatment option. Because the clinical presentation varies, the diagnosis requires a high index of suspicion for both the clinician and the pathologist.

Clinical Outcomes of Routine Awake Prone Positioning in COVID-19 Patients: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Before coronavirus disease 2019 (COVID-19) emerged, proning had been demonstrated to improve oxygenation in those with acute hypoxic respiratory failure and be performed in non-intensive care settings. This benefit was further exemplified by the COVID-19 pandemic, leading to awake prone positioning (APP). We assessed the efficacy of routine APP versus standard care in preventing death and invasive mechanical ventilation (IMV) in non-intubated hypoxic COVID-19 patients. PubMed, Cochrane Library, Scopus, and medRxiv databases were used from January 1st, 2020, to January 15th, 2022, to identify randomized controlled trials (RCTs). Routine APP group were encouraged to be self-prone, whereas the standard care group received care according to local clinical practice and allowed APP crossover as rescue therapy. We included eight COVID-19 RCTs assessing 809 APP vs. 822 standard care patients. APP group had less IMV requirement (26.5% vs. 30.9%; OR - odds ratio 0.77; P=0.03) than the standard care group, with subgroup analysis showing greater benefit (32.5% vs. 39.1%; OR 0.75; P=0.02) for those mainly requiring oxygen support of non-invasive mechanical ventilation (NIMV) and high-flow nasal cannula (HFNC). The time to IMV initiation was similar (mean 8.3 vs. 10.0 days; P=0.66) for patients requiring NIMV and HFNC. Patients mainly receiving supplemental oxygen and non-rebreather masks had improved oxygenation parameters, although not statistically significant. Other outcomes involving all-cause hospital mortality, hospital and ICU (intensive care unit) length of stay, and adverse events were comparable. APP appeared to be an important modality for reducing IMV requirements, especially in those requiring NIMV and HFNC.

A 49-year-old man with ischemic cardiomyopathy and persistent hemoptysis for eighteen months

Idiopathic pulmonary hemosiderosis (IPH) is a rare cause of recurrent episodes of diffuse alveolar hemorrhage (DAH). IPH commonly manifests with hemoptysis, radiologic chest infiltrates and anemia. The etiology of IPH is unknown, but an immunologic mechanism is widely speculated. The definitive diagnosis of IPH requires a thorough exclusion of other causes of DAH, such as infections, inflammation, malignancy, cardiac diseases, drug and toxin exposure, and medications. Due to the rarity of the disease, a diagnosis is often delayed by years. We present the case of a 49-year-old man with ischemic cardiomyopathy who presented with hemoptysis for eighteen months. Serologic workup was negative for vasculitides and autoimmune diseases. Bronchoscopy revealed DAH. A surgical lung biopsy showed 'bland pulmonary hemorrhage.' A right heart catheterization ruled out cardiac causes of DAH. The patient was diagnosed with IPH and started on systemic corticosteroids with rapid improvement of hemoptysis.

Adult patients with idiopathic pulmonary hemosiderosis: a comprehensive review of the literature

Idiopathic pulmonary hemosiderosis (IPH) is a rare disease without a known incidence or prevalence in adults. Our knowledge of this entity is limited as there is no prospective or retrospective study with a reasonable number of patients. The objective is to describe the demographics, clinical manifestations, diagnosis, treatment, and prognosis of adult patients with IPH. The Medline and Embase databases were searched from inception to 2021 with appropriate search formulas to identify relevant articles following strict inclusion and exclusion criteria. Statistical analyses were performed for the entire cohort and prespecified subgroups. A total of 84 patients were identified. The majority of patients were males 54/84 (64.3%). The median age was 27 years. The manifesting symptoms were present in the following frequencies: anemia 76/83 (91.6%), dyspnea 71/83 (85.5%), hemoptysis 70/84 (83.3%), cough 22/84 (26.2%), and chest pain 9/84 (10.7%). The classic triad was present in 61/84 (79%) patients. The mean hemoglobin during the initial presentation was 8.4 gm/dL. A total of 16/57 (19.5%) tested positive for autoantibodies. The median delay in the diagnosis of IPH was 1.02 years. Immunosuppressive therapy was prescribed in 49/79 (62%) patients, and recurrence occurred in more than half of the patients 36/66 (54.5%). A total of 63/79 (79.7%) patients were alive during the final follow-up. IPH is more common in young adults with a male predominance. A high index of suspicion is necessary to attain an early diagnosis and possibly reduce the short-term mortality of nearly 20% and long-term complications.

Comparison of clinical characteristics and outcomes of COVID-19 patients undergoing early versus late intubation from initial hospital admission: A systematic review and meta-analysis

BACKGROUND

The true impact of intubation and mechanical ventilation in coronavirus disease 2019 (COVID-19) patients remains controversial.

METHODS

We searched Pubmed, Cochrane Library, Embase, and Web of Science databases from inception to October 30th, 2021 for studies containing comparative data of COVID-19 patients undergoing early versus late intubation from initial hospital admission. Early intubation was defined as intubation within 48 h of hospital admission. The primary outcomes assessed were all-cause in-hospital mortality, renal replacement therapy (RRT), and invasive mechanical ventilation (IMV) duration.

RESULTS

Four cohort studies with 498 COVID-19 patients were included between February to August 2020, in which 28.6% had early intubation, and 36.0% underwent late intubation. Although the pooled hospital mortality rate was 32.1%, no significant difference in mortality rate was observed (odds ratio [OR] 0.81; 95% confidence interval 0.32-2.00; P = 0.64) among those undergoing early and late intubation. IMV duration (mean 9.62 vs. 11.77 days; P = 0.25) and RRT requirement (18.3% vs. 14.6%; OR 1.19; P = 0.59) were similar regardless of intubation timing. While age, sex, diabetes, and body mass index were comparable, patients undergoing early intubation had higher sequential organ failure assessment (SOFA) scores (mean 7.00 vs. 5.17; P < 0.001).

CONCLUSIONS

The timing of intubation from initial hospital admission did not significantly alter clinical outcomes during the early phase of the COVID-19 pandemic. Higher SOFA scores could explain early intubation. With the advancements in COVID-19 therapies, more research is required to determine optimal intubation time beyond the first wave of the pandemic.

Association between idiopathic pulmonary hemosiderosis and celiac disease in pediatric patients: A scoping review of the literature over the past 50 years

INTRODUCTION

Idiopathic pulmonary hemosiderosis (IPH) is a rare cause of diffuse alveolar hemorrhage, the mechanism of which is currently unknown. Nearly one-third of pediatric patients with IPH test positive for Celiac disease (CD) serology. Several hypothetical mechanisms have been proposed to unify the coexistence of these two entities, also referred to as Lane-Hamilton syndrome (LHS).

METHOD

This manuscript is a scoping review of the medical literature. Medline, Embase, and PubMed Central databases were searched between 1971 and 2021 with appropriate search words to identify all cases of pediatric LHS.

RESULTS

A total of 20 manuscripts with 23 pediatric patients with LHS were identified. The mean age was 11 years, and 13/23 (56.5%) of the children were boys. Hemoptysis was present in 57% of patients during diagnosis. Bronchoscopy with bronchoalveolar lavage demonstrating hemosiderin laden macrophages was the primary mode of diagnostic confirmation. Only three patients underwent lung biopsy. Any significant GI symptom was reported in a minority of patients (22%). Iron deficiency anemia on presentation was described in 83% of children. The majority of patients were malnourished. Serology for CD was positive in all patients, as was the histopathologic analysis of the small bowel biopsy. No patients had any other autoantibody positivity. The introduction of gluten free diet (GFD) was associated with a positive response in 20/23 patients.

CONCLUSION

All pediatric patients with IPH should undergo screening for CD. Low serum ferritin in patients with IPH could be suggestive of coexisting CD. Strict GFD should be tried as the initial therapy.

The Spectrum of Autoantibodies in Adult Patients With Idiopathic Pulmonary Hemosiderosis: A Brief Review of the Literature

While autoimmune antibodies or autoantibodies have been reported sporadically in adult patients with idiopathic pulmonary hemosiderosis (IPH), their true prevalence is unknown. The question as to whether any difference exists between antibody-positive and negative patients has not been explored. The primary objective of this paper was to assess the spectrum of autoantibody testing and its positivity rate. The other objectives included a comparative analysis of demographics, symptom onset, clinical manifestations, and differences in clinical outcomes between antibody-positive (cohort A) and negative (cohort B) patients. To that end, we conducted a retrospective review of the relevant published literature. Multiple databases were searched to retrieve studies published between 1990 and 2022.

A total of 35 studies, involving 38 patients, were identified. Five of these patients had a positive autoantibody. Patients in cohort A were older and more likely to be male. The frequencies of testing for these antibodies were as follows: antineutrophil cytoplasmic antibody (ANCA): 37/38 (97.4%), antinuclear antibody (ANA): 31/38 (81.6%), and anti-glomerular basement membrane antibody (anti-GBM): 30/38 (78.9%); 5/38 (13.2%) patients tested positive for an autoantibody, and two of these patients were positive for ANA, two for antithyroid antibody, and one patient tested positive for ANCA, rheumatoid factor (RF), and granulocyte monocyte-colony stimulating factor (GM-CSF) antibody. There was no difference between the cohorts regarding their clinical presentations, recurrence risks, and survival.

The occurrence of autoantibodies is uncommon in adult IPH patients. This is in contrast with the pediatric IPH patient population, where the prevalence is much higher (26.4% vs. 13.2%), and the antibodies are more diverse. Unlike pediatric patients, adult patients with autoantibodies do not necessarily have worse outcomes.

Proposed Pathogenesis of Diffuse Alveolar Hemorrhage in Idiopathic Pulmonary Hemosiderosis

Idiopathic pulmonary hemosiderosis (IPH) is a rare disease that causes diffuse alveolar hemorrhage (DAH). The latest data suggests an immunologic origin of IPH, and a new name, immune mediated pulmonary hemosiderosis (ImPH), has been proposed. However, the exact immunologic mechanism has remained elusive for nearly eight decades despite extensive research, including detailed histopathologic analysis. Although several hypotheses have been proposed to describe the pathobiology of IPH, none of them explain the clinical and histopathologic findings conclusively. In this manuscript, we have presented a new hypothesis for the pathogenesis of DAH in IPH. We hypothesize that DAH in IPH is not immunocomplex mediated but due to histamine, eosinophilic cationic protein (ECP), and possibly vascular endothelial growth factor (VEGF). These bioactive proteins induce endothelial and alveolar epithelial damage, leading to the peri-capillary and intraalveolar escape of RBCs. The deformability of the RBC likely also plays a role. The supranormal secretion of histamine, ECP and VEGF occurs in genetically predisposed individuals with an aberrant immunologic response. The histamine is released from the basophils and possibly the mast cells in response to cytokines secreted by activated lymphocytes. The lymphocyte activation occurs after exposure to a known (gluten) or unknown antigen. The same lymphocyte-derived cytokines also induce eosinophilic degranulation of ECP and VEGF in the pulmonary circulation. We believe that our hypothesis unifies the observed clinical variabilities and histopathologic findings in IPH, and we hope that would promote future research in the field of IPH.

Prevalence of autoantibodies in pediatric patients with idiopathic pulmonary hemosiderosis: a scoping review of the literature in the period 1980-2021

Idiopathic pulmonary hemosiderosis (IPH) is a rare disease of unknown etiology. Due to the frequent findings of autoimmune antibodies - autoantibodies, immunologic causation of the diffuse alveolar hemorrhage in IPH has been proposed, to assess the prevalence/frequency and type of autoantibodies in pediatric patients with IPH. In addition, the patient demographics, diagnostic modalities used to diagnose IPH, treatment, and outcomes were also evaluated. Scoping review: The PubMed, Medline, and Embase databases were searched with appropriate MeSH terms to identify relevant papers consistent with the defined inclusion criteria. Thirteen observational studies comprising a total of 352 pediatric patients were included in this review. The majority of subjects were girls 217 out of 352 (61.6%). The mean and median ages of patients ranged from 3.1-6.5 years to 2.3-7 years, respectively. In the 10 studies that specified the number of patients in their cohorts with either at least one positive autoantibody or no antibody, the overall prevalence of autoantibodies was 76 out of 288 patients (26.4%). The prevalence of specific antibodies was as follows: ANA, 20.3%; ANCA, 17%; anti-dsDNA, 9.1%; RF, 12%; anti-SMA, 23.2%; and celiac antibodies, 25.9%. Cow's milk protein allergy was present in 16.2% of the children. The significance of an association between IPH and the presence of autoantibodies has not been clarified. The autoantibodies could be suggestive of an overall immune dysregulation rather than causation. However, limited evidence based on a single study suggests that the presence of ANA may be associated with a higher risk of recurrence and worse outcomes. Further research, including prospective studies, will be crucial to explore a possible genetic linkage between vasculitides, systemic rheumatologic diseases, and IPH.

Comparative Analysis of Adult Patients With Idiopathic Pulmonary Hemosiderosis and Lane-Hamilton Syndrome: A Systematic Review of the Literature in the Period 1971-2022

Idiopathic pulmonary hemosiderosis (IPH) causes diffuse alveolar hemorrhage (DAH) by a yet unknown mechanism. The coexistence of IPH and celiac disease (CD), also known as Lane-Hamilton syndrome (LHS), has been reported in both pediatric and adult patients. The objective of this study was to compare demographics, clinical and radiologic findings, treatment, and outcomes between adult patients with IPH and LHS.

This is a systematic review of the literature. Multiple databases were searched using appropriate formulas to identify relevant articles. A total of 60 studies reporting 65 patients were included in the review. Forty-nine of these patients had IPH and 16 had LHS. The prevalence of anti-CD antibodies among tested patients was 13/22 (59%). The symptom onset and diagnosis of IPH occurred earlier in patients with LHS. The median delay in diagnosis was the same between the two groups (52 weeks). The classic triad was more likely to be present in patients with LHS. Only 20% of patients in the LHS cohort had any significant gastrointestinal (GI) symptoms at the time of IPH diagnosis. A gluten-free diet alone was effective in the majority of patients. Fewer patients in the LHS cohort received systemic corticosteroid than the IPH cohort. The recurrence and mortality in patients with LHS appear to be less than in the IPH cohort. The prevalence of CD is 25% in adult patients with IPH. Patients with LHS may have a milder course than patients without CD. Serologic testing for CD should be performed in all patients diagnosed with IPH.

An Unusual Case of Explosive Pleuritis without Mediastinal Shift

Explosive pleuritis (EP) is an under-reported condition. Although there is no agreed-upon definition, generally, the term EP denotes a dramatic clinical and radiologic progression of pleural space inflammation in the setting of pneumonia. The pleural space inflammation leads to the formation of loculated complex pleural effusion or empyema, and pleural adhesion within a matter of hours, typically in less than 24 hours. Radiologically, these changes are manifested as opacification of the hemithorax with or without contralateral mediastinal shift. Streptococcal pneumonia is the most common cause of EP. Here we present a case and discuss the clinical, microbiologic, radiologic, and treatment aspects of EP. We also scrutinize the medical literature to compare the previously reported cases.

Pneumomediastinum: A Rare Complication of Endobronchial Ultrasound Guided Fine Needle Aspiration

Endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) is a commonly performed outpatient procedure used for the diagnosis, staging of lung cancer, and the evaluation of thoracic lymphadenopathy of unknown origin. With the advent of this minimally invasive technology, mediastinoscopy, once the gold standard, has fallen out of favour. Pneumomediastinum is a rare complication of EBUS-TBNA and can often be managed conservatively. We present a case of a 52-year-old female who developed pneumomediastinum following EBUS-TBNA and improved with expectant management in the emergency department. We discuss the proposed pathophysiology of this rare occurrence that usually follows a benign course. Severe complications, such as mediastinitis and tracheal tear, need to be excluded promptly.

Indications, Clinical Utility, and Safety of Bronchoscopy in COVID-19

BACKGROUND

Bronchoscopy is an aerosol-generating procedure and routine use for patients with coronavirus disease 2019 (COVID-19) has been discouraged. The purpose of this review was to discuss the indications, clinical utility, and risks associated with bronchoscopy in patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia.

METHODS

A literature search was performed by using appropriate key terms to identify all relevant articles from medical literature databases up to August 1, 2021.

RESULTS

Twelve cohorts (9 retrospective and 3 prospective) reported the performance of 2,245 bronchoscopies in 1,345 patients with COVID-19. The majority of the subjects were male. Nearly two thirds of the bronchoscopies (62%) were performed for therapeutic indications; the rest (38%) were for diagnostic purposes. Bronchoalveolar lavage had an overall yield of 33.1% for SARS-CoV-2 in subjects with negative results of real-time polymerase chain reaction on nasopharyngeal specimens. The incidence of a secondary infection ranged from 9.3% to as high as 65%. Antibiotics were changed in a significant number of the subjects (14%-83%) based on the bronchoscopic findings. Bronchoscopy was well tolerated in most subjects except those who required noninvasive ventilation, in whom the intubation rate after the procedure was 60%. The rate of transmission of SARS-CoV-2 among health-care workers was minimum.

CONCLUSIONS

Bronchoscopy in patients with COVID-19 results in a significant change in patient management. Transmission of SARS-CoV-2 seems to be low with consistent use of appropriate personal protective equipment by health-care workers. Therefore, bronchoscopic evaluation should be considered for all diagnostic and therapeutic indications in this patient population.

Differentiation of idiopathic pulmonary hemosiderosis from rheumatologic and autoimmune diseases causing diffuse alveolar hemorrhage: establishing a diagnostic approach

This narrative review provides an overview of diffuse alveolar hemorrhage (DAH) associated with rheumatologic and autoimmune diseases and their differentiation from idiopathic pulmonary hemosiderosis (IPH). Relevant immunologic diseases associated with DAH are discussed, and a diagnostic flowchart is proposed to establish a "definitive" diagnosis of IPH within the spectrum of DAH. IPH is a rare cause of recurrent DAH both in children and adults. In adults, a definitive diagnosis of IPH requires a lung biopsy and histopathologic examination demonstrating intraalveolar hemorrhage, hemosiderin-laden macrophages, and a variable degree of fibrosis in the absence of both capillaritis and cellular inflammation. The presence of small vessel vasculitis points towards immunologic, well-differentiated, or sometimes undifferentiated rheumatologic diseases. However, it is essential to recognize that many rheumatologic diseases may in the initial phase present with DAH without any evidence of capillaritis, thus mimicking IPH. Although not definitely established, it is likely that immunologic processes are involved in IPH, and we, therefore, suggest the consideration of a more suitable term for the disease, e.g., "Immune-mediated Pulmonary Hemosiderosis" to acknowledge the aberrancy in the immune parameters and a positive response to immunosuppressive therapy.

A 26-year old young male with severe anemia

Testicular choriocarcinoma is a subset of Non-Seminomatous Germ Cell Tumors (NSGT) which is considered the rarest and most aggressive testicular cancer. It primarily affects males between the ages of 25–30 years. Unlike other testicular neoplasms that carry a cure rate of 95%, choriocarcinoma has significantly lower rate of cure. Therefore, early detection and prompt treatment is necessary to improve survival. We present an unusual case of Choriocarcinoma presenting as severe anemia along with distant metastases to lung and brain. We also discuss diagnostic approach and treatment challenges in patients with Choriocarcinoma.

Lung transplant to manage end-stage lung disease due to idiopathic pulmonary hemosiderosis: A review of the literature

Idiopathic pulmonary hemosiderosis (IPH) is a rare immunological disease with a genetic predisposition. It is characterized by recurrent episodes of diffuse alveolar hemorrhage (DAH). Timely use of immunosuppressive medications has significantly improved overall outcomes, including mortality. Still, uncontrolled and frequent episodes of DAH can eventually cause pulmonary fibrosis, leading to end-stage lung disease (ESLD). The objective of the present project was to scrutinize the literature and summarize the demographic, clinical, radiological, and histopathological features, as well as the overall outcomes, in this patient population following lung transplant. The Medline database was searched using the PubMed platform. Articles published in English between 1960 and 2020 were included in the search. Different search terms were used to identify all patients who underwent lung transplantation to manage ESLD due to IPH. Only four cases of lung transplantation have been reported in the literature in patients with IPH. All but one of these underwent deceased donor lung transplant; recurrence was reported in two of these patients and suspected in the third. One patient received living donor lung transplant and had no recurrence during a five-year follow-up. Patients with IPH should not be excluded from lung transplantation because the disease may not recur in all patients, and even when it does recur it can be promptly treated by increasing immunosuppression.

Pattern of Glomerular Disease in a Tertiary Care Hospital of Bangladesh

Glomerular disease is one of the most important causes of chronic kidney disease in developing countries like Bangladesh as well as the whole world. The pattern of glomerular disease varies in different countries and can have different clinical presentations. The aim of the study was to analyze the clinical profile and to determine the histological pattern of glomerular diseases in a large tertiary care hospital in Bangladesh. All kidney biopsies performed in Mymensingh Medical College Hospital, Bangladesh from October 2018 to March 2020 were prospectively analyzed in the study. A total of 101 patients with kidney biopsy were examined by clinical and laboratory findings and by light and immuno-fluorescence microscopy. The mean age was 30.0±14.6 years and 50(49.5%) were male and 51(50.5%) were female with a male to female ratio of 1:1. The clinical syndromes namely nephrotic syndrome, nephritic syndrome, nephrito-nephrotic presentation, RPGN like presentation, macroscopic haematuria and asymptomatic urine abnormality were present in 31.7%, 34.5%, 22.8%, 11.9%, 19.8% and 10.9% patients respectively. The most common histological varieties found in the study were mesangial proliferative glomerulonephritis (MesPGN) (18.8%) and focal segmental glomerulosclerosis (FSGS) (18.8%). Other histopathological pattern among the studied subjects revealed minimal change disease (MCD) in 5.9%, membranous nephropathy (MN) in 7.9%, membranoproliferative glomerulonephritis (MPGN) in 16.8%, IgA nephropathy in 5%, IgM nephropathy in 2%, IgG nephropathy in 2%, diffuse proliferative glomerulonephritis (DPGN) in 1%, focal proliferative glomerulo-nephritis (FPGN) in 3%, crescentic GN in 3%, lupus nephritis (LN) in 13.9%, amyloidosis in 1% and fibrillary glomerulopathy in 1% patient. The pattern of glomerular disease found in this study was similar to other studies performed in Bangladesh with a little variation. It may guide the future researchers to establish a national kidney biopsy registry in Bangladesh.

Liposteroid Therapy for Idiopathic Pulmonary Hemosiderosis: A Scoping Review of the Literature

Idiopathic pulmonary hemosiderosis (IPH) is a rare cause of diffuse alveolar hemorrhage (DAH). Glucocorticosteroids (CS) represent the first line therapy for IPH. Although most patients respond to CS, steroid refractoriness is seen in an appreciable minority of patients. This paper reviews and evaluates the efficacy and safety profile of liposomal dexamethasone 21-palmitate (liposteroid) for the treatment of IPH. Medline, Embase and Web of Science biomedical databases were searched between 1980 and 2020 to identify papers describing patients with IPH, who were treated with liposteroid. A total of five articles were identified. Four in the form of case reports and one as a case series. A total of 12 pediatric patients (5 boys, 7 girls) were identified, with a median age of 2.3 years (range 0.5-8.6). Liposteroid therapy in intravenous doses ranging 0.06-0.1 mg/kg body weight appeared to be effective for both remission induction therapy, and maintenance therapy. There was no mortality among patients treated with liposteroid, either in the acute phase or during follow-up. The majority of patients for whom long-term follow-up data were available, were cured or in disease remission. No acute adverse events were reported, and long-term side effects were minimal and tolerable. Liposteroid represents a potential alternative or supplement to conventional CS therapy, as it appears to be more efficacious and associated with fewer side effects. Larger prospective, controlled trials are necessary to be able to define more precisely the therapeutic role of liposteroid in IPH.

Short Review of Liposteroid: A Novel Targeted Glucocorticoid Preparation for Treatment of Autoimmune and Inflammatory Diseases

This paper briefly reviews the safety and efficacy of liposteroid in different inflammatory and non-inflammatory diseases. Corticosteroids (CS) are the first-line therapy in many inflammatory and autoimmune disorders. Although highly efficacious, long-term use of CS is limited due to the occurrence of significant side effects. Liposteroid, which is a liposomal formulation of dexamethasone palmitate, possess more potent anti-inflammatory and immunosuppressive properties compared to dexamethasone sodium phosphate. These two formulations have markedly different lipid solubility, resulting in different pharmacokinetic and pharmacodynamic properties. Liposteroid has been used with success in patients with rheumatoid arthritis, macrophage activation syndrome, and idiopathic pulmonary hemosiderosis. In addition, liposteroid has been used in some non-inflammatory diseases. Moreover, we conceive that liposteroid may have a beneficial effect in patients, who are critically ill due to COVID-19, and suffer from the macrophage activation syndrome.

Successful use of endobronchial valve for persistent air leak in a patient with COVID-19 and bullous emphysema

Patients with SARS-CoV-2 pneumonia can suffer from pneumothorax and persistent air leak (PAL). The pneumothorax occurs with or without pre-existing lung disease. PAL refers to air leak lasting more than 5-7 days and arises due to bronchopleural or alveolopleural fistula. The management of PAL can be challenging as a standard management guideline is lacking. Here we present the case of a 42-year-old smoker with COVID-19 who presented to the hospital with fever, cough, acute left-sided chest pain and shortness of breath. He suffered from a large left-sided pneumothorax requiring immediate chest tube drainage. Unfortunately, the air leak persisted for 13 days before one-way endobronchial valve (EBV) was used with complete resolution of the air leak. We also review the literature regarding other cases of EBV utilisation for PAL in patients with COVID-19.

A systematic review and meta-analysis comparing the clinical characteristics and outcomes of COVID-19 and influenza patients on ECMO

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) is a valuable rescue therapy to treat refractory hypoxemia caused by influenza. The present meta-analysis aimed to compare the clinical characteristics and outcomes of ECMO between COVID-19 and influenza.

METHODS

We searched the PubMed, Cochrane Library, SCOPUS, and Web of Science databases from inception to May 1, 2021. The included studies compared the clinical characteristics and outcomes of ECMO between adults with COVID-19 and those with influenza.

RESULTS

The study included four retrospective cohorts involving a total of 129 patients with COVID-19 and 140 with influenza who were treated using ECMO. Clinical characteristics were similar between the COVID-19 and influenza groups, including body mass index (BMI), diabetes mellitus, hypertension, and immunocompromised status. A higher proportion of patients with COVID-19 on ECMO were male (75.9% vs. 62.9%; P = 0.04). There was no difference between the groups in terms of illness severity based on sequential organ failure assessment (SOFA) score or serum pH. Patients with COVID-19 had a longer mean duration of mechanical ventilation before ECMO (6.63 vs. 3.38 days; P < 0.01). The pooled mortality rate was 43.8%. The mean ECMO duration (14.13 vs. 12.55 days; P = 0.25) and mortality rate (42.6% vs. 45.0%; P = 0.99) were comparable between the groups.

CONCLUSION

Clinical characteristics, ECMO duration, and mortality were comparable between patients with COVID-19 and those with influenza who required ECMO to treat refractory hypoxemia. The duration of mechanical ventilation before ECMO did not influence outcomes. Patients with COVID-19 benefit from ECMO salvage therapy similarly to those with influenza.

Clinical Characteristics Between Survivors and Nonsurvivors of COVID-19 Patients Requiring Extracorporeal Membrane Oxygenation (ECMO) Support: A Systematic Review and Meta-Analysis

Background: The use of extracorporeal membrane oxygenation (ECMO) in coronavirus disease 2019 (COVID-19) for refractory respiratory failure, severe cardiac dysfunction, and bridge to lung transplantation has been steadily increasing during the ongoing global pandemic. Objective: Our meta-analysis aims to compare the clinical characteristics between COVID-19 survivors and nonsurvivors requiring ECMO support. Methods: A systematic search of Pubmed, Cochrane, Embase, Scopus, and Web of Science databases was performed between December first, 2019, to June first, 2021. Studies with comparative data of COVID-19 ECMO patients were selected, in which clinical characteristics and complications were assessed. Results: Sixteen cohort studies involving 706 COVID-19 patients requiring ECMO support with pooled mortality rate of 40% were included. Younger age (mean 51 years vs 55 years; P < .001), fewer comorbidities (23% vs 31%; odds ratio [OR] 0.55; P  =  .02), and less renal replacement therapy (RRT) (21% vs 39%; OR 0.41; P  =  .007) and vasopressor (76% vs 92%; OR 0.35; P  =  .008) requirement were demonstrated in COVID-19 survivors requiring ECMO support than nonsurvivors. Survivors also had higher pre-ECMO pH (mean 7.33 vs 7.26; P < .001) than nonsurvivors. No difference was observed in gender, body mass index, duration of mechanical ventilation (MV) before ECMO support initiation, total ECMO support duration, and pre-ECMO parameters of PaO2/FiO2 ratio, tidal volume (mL/kg), positive end-expiratory pressure, and plateau pressure. The rate of bleeding complications was lower in survivors (32% vs 59%; OR 0.36; P  =  .001) than nonsurvivors, but no difference was observed in thromboembolism and secondary infections. Conclusions: We found advanced age, multiple comorbidities, lower pre-ECMO pH, greater RRT, and vasopressor requirements, and bleeding are predictors of death in COVID-19 patients requiring ECMO support. The duration of MV before ECMO support initiation and total ECMO support duration was similar among survivors and nonsurvivors. Our study results have important clinical implications when considering ECMO support in critically ill COVID-19 patients.

Comparing the clinical characteristics and outcomes of COVID-19-associate pulmonary aspergillosis (CAPA): a systematic review and meta-analysis

PURPOSE

Invasive pulmonary aspergillosis has been increasingly recognized in COVID-19 patients, termed COVID-19-associate pulmonary aspergillosis (CAPA). Our meta-analysis aims to assess the clinical characteristics and outcomes of patients diagnosed with CAPA compared to those without CAPA.

METHODS

We searched the Pubmed, Cochrane Library, SCOPUS, and Web of Science databases for studies published between January 1, 2020 and August 1, 2021, containing comparative data of patients diagnosed with CAPA and those without CAPA.

RESULTS

Eight cohort studies involving 729 critically ill COVID-19 patients with comparative data were included. CAPA patients were older (mean age 66.58 vs. 59.25 years; P = 0.007) and had underlying chronic obstructive pulmonary disease (COPD) (13.7 vs. 6.1%; OR 2.75; P = 0.05). No differences in gender, body mass index (BMI), and comorbidities of diabetes and cancer were observed. CAPA patients were more likely to receive long-term corticosteroid treatment (15.0 vs. 5.3%; OR 3.53; P = 0.03). CAPA patients had greater severity of illness based on sequential organ failure assessment (SOFA) score with a higher all-cause in-hospital mortality rate (42.6 vs. 26.5%; OR 3.39; P < 0.001) and earlier ICU admission from illness onset (mean 11.00 vs. 12.00 days; P = 0.003). ICU length of stay (LOS), invasive mechanical ventilation (IMV) duration, the requirement of inotropic support and renal replacement therapy were comparable between the two groups.

CONCLUSIONS

CAPA patients are typically older with underlying COPD and received long-term corticosteroid treatment. Furthermore, CAPA is associated with higher SOFA scores, mortality, and earlier onset of ICU admission from illness onset.

Does COVID-19 pneumonia signify secondary organizing pneumonia?: A narrative review comparing the similarities between these two distinct entities

Multiple observational studies have described the similarities between COVID-19 pneumonia and organizing pneumonia (OP). These two entities clinically manifest with mild and subacute respiratory symptoms, often with a delayed diagnosis due to the atypical ARDS and silent hypoxemia presentation. Radiological features are often indistinguishable between the two. With the increase in antemortem lung biopsies and autopsies being performed, more histopathological findings of OP and its variant, acute fibrinous and organizing pneumonia (AFOP), are being diagnosed. These entities are known complications of viral infections as a delayed immunological process, explaining the favorable response to corticosteroids. Clinicians should be vigilant to diagnose this under-recognized entity of secondary OP in people with COVID-19 when clinical deterioration occurs, especially with compatible radiologic findings and recent cessation of corticosteroids. Despite the proven benefits of corticosteroids in treating COVID-19, treatment approaches can be more effective as OP often requires higher doses and a more prolonged therapy duration for remission and preventing relapses. The purpose of our narrative review is to compare the similarities between COVID-19 pneumonia and OP, emphasizing the clinical, radiological, and histopathological features based on the evidence available in the literature.

Pleural abnormalities in COVID-19: a narrative review

Objective

This narrative review aims to provide a detailed overview of pleural abnormalities in patients with coronavirus disease 19 or COVID-19.

Background

Severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2) is a novel beta coronavirus responsible for COVID-19. Although pulmonary parenchymal and vascular changes associated with COVID-19 are well established, pleural space abnormalities have not been the primary focus of investigations.

Methods

Narrative overview of the medical literature regarding pleural space abnormalities in COVID-19. The appropriate manuscripts were identified by searching electronic medical databases and by hand searching the bibliography of the identified papers. Pleural abnormalities on transverse and ultrasound imaging are discussed. The incidence, clinical features, pathophysiology, and fluid characteristics of pleural effusion are reviewed. Studies reporting pneumothorax and pneumomediastinum are examined to evaluate for pathogenesis and prognosis. A brief comparative analysis of pleural abnormalities among patients with COVID-19, severe acute respiratory syndrome (SARS), and Middle Eastern respiratory syndrome (MERS) has been provided.

Conclusions

Radiologic pleural abnormalities are common in COVID-19, but the incidence of pleural effusion appears to be low. Pneumothorax is rare and does not independently predispose the patient to worse outcomes. SARS-CoV-2 infects the pleural space; however, whether the pleural fluid can propagate the infection is unclear.