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Introduction: Retrospective studies have shown improved diagnostic yield of combined cytology and cell blocks specimens from endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) with variable additional yields in cell blocks. In this prospective study, we assessed the diagnostic performance of cytology and cell blocks in patients undergoing EBUS-TBNA. Methods: This was a single-center, cross-sectional study conducted between December 2017 and November 2019 including patients aged ≥18 years with mediastinal lymphadenopathy. EBUS-TBNA was performed under conscious sedation using 22G needles. Both cytology smears and cell blocks by the tissue coagulum clot technique were prepared for each patient without rapid on-site evaluation. Results: Data were analyzed for 93 patients (mean age 54.25 ± 13.7 years, 73 males) where both cytology and cell blocks were available. Sample adequacy was 100%. Overall diagnostic yield either by cytology or cell block was 83%. Cytology yield was 79.6%, whereas cell block was diagnostic in 73% of patients (P < 0.001). The overall additional yield of cell blocks was 3.2%. Cell blocks had additional yields of 1.8%, 0%, and 14.3% in malignancy, tuberculosis, and sarcoidosis, respectively. Tumor histology was better identified in 76% of positive cell blocks, and accurate histological subtyping was possible in 32.6% cases. Immunohistochemistry was feasible in 82.5% of all positive cell blocks, and these were judged to be adequate for the mutational analysis. Conclusions: Compared to cytology, EBUS-TBNA cell blocks did not significantly increase the overall diagnostic yield in unselected patients. However, cell blocks are beneficial in the characterization of tumor morphology and histological subtyping of lung cancer.

Introduction Healthcare workers (HCWs) are vulnerable to getting infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Preventing HCWs from getting infected is a priority to maintain healthcare services. The therapeutic and preventive role of ivermectin in coronavirus disease 2019 (COVID-19) is being investigated. Based on promising results of in vitro studies of oral ivermectin, this study was conducted with the aim to demonstrate the prophylactic role of oral ivermectin in preventing SARS-CoV-2 infection among HCWs at the All India Institute of Medical Sciences (AIIMS) Bhubaneswar. Methods A prospective cohort study was conducted at AIIMS Bhubaneswar, which has been providing both COVID and non-COVID care since March 2020. All employees and students of the institute who provided written informed consent participated in the study. The uptake of two doses of oral ivermectin (300 μg/kg/dose at a gap of 72 hours) was considered as exposure. The primary outcome of the study was COVID-19 infection in the following month of ivermectin consumption, diagnosed as per Government of India testing criteria (real-time reverse transcriptase polymerase chain reaction [RT-PCR]) guidelines. The log-binomial model was used to estimate adjusted relative risk (ARR), and the Kaplan-Meier failure plot was used to estimate the probability of COVID-19 infection with follow-up time. Results Of 3892 employees, 3532 (90.8%) participated in the study. The ivermectin uptake was 62.5% and 5.3% for two doses and single dose, respectively. Participants who took ivermectin prophylaxis had a lower risk of getting symptoms suggestive of SARS-CoV-2 infection (6% vs 15%). HCWs who had taken two doses of oral ivermectin had a significantly lower risk of contracting COVID-19 infection during the following month (ARR 0.17; 95% CI, 0.12-0.23). Females had a lower risk of contracting COVID-19 than males (ARR 0.70; 95% CI, 0.52-0.93). The absolute risk reduction of SARS-CoV-2 infection was 9.7%. Only 1.8% of the participants reported adverse events, which were mild and self-limiting. Conclusion Two doses of oral ivermectin (300 μg/kg/dose given 72 hours apart) as chemoprophylaxis among HCWs reduced the risk of COVID-19 infection by 83% in the following month. Safe, effective, and low-cost chemoprophylaxis has relevance in the containment of pandemic alongside vaccine.

A 20-year old female presented to our department with complaints of sudden-onset dyspnea and right-sided chest pain for the last month [...]

Background Ivermectin is one among several potential drugs explored for its therapeutic and preventive role in SARS-CoV-2 infection. The study was aimed to explore the association between ivermectin prophylaxis and the development of SARS-CoV-2 infection among healthcare workers. Methods A hospital-based matched case-control study was conducted among healthcare workers of AIIMS Bhubaneswar, India, from September to October 2020. Profession, gender, age and date of diagnosis were matched for 186 case-control pairs. Cases and controls were healthcare workers who tested positive and negative, respectively, for COVID-19 by RT-PCR. Exposure was defined as the intake of ivermectin and/or hydroxychloroquine and/or vitamin-C and/or other prophylaxis for COVID-19. Data collection and entry was done in Epicollect5, and analysis was performed using STATA version 13. Conditional logistic regression models were used to describe the associated factors for SARS-CoV-2 infection. Results Ivermectin prophylaxis was taken by 76 controls and 41 cases. Two-dose ivermectin prophylaxis (AOR 0.27, 95% CI, 0.15–0.51) was associated with a 73% reduction of SARS-CoV-2 infection among healthcare workers for the following month. Those involved in physical activity (AOR 3.06 95% CI, 1.18–7.93) for more than an hour/day were more likely to contract SARS-CoV-2 infection. Type of household, COVID duty, single-dose ivermectin prophylaxis, vitamin-C prophylaxis and hydroxychloroquine prophylaxis were not associated with SARS-CoV-2 infection. Conclusion Two-dose ivermectin prophylaxis at a dose of 300 μg/kg with a gap of 72 hours was associated with a 73% reduction of SARS-CoV-2 infection among healthcare workers for the following month. Chemoprophylaxis has relevance in the containment of pandemic.

Background: India introduced BBV152/Covaxin and AZD1222/Covishield vaccines from January 2021. We estimated effectiveness of these vaccines against severe Coronavirus disease 2019 (COVID-19) among individuals aged >=45 years. Methods: We did a multi-centric, hospital-based, case–control study between May and July 2021. Cases were severe COVID-19 patients and controls were COVID-19 negative individuals from 11 hospitals. Vaccine effectiveness (VE) was estimated for full (2 doses ≥14days) and partial (1 dose ≥21 days) vaccination; duration between two vaccine doses and against the Delta variant. We used a random effects logistic regression model to calculate adjusted odds ratios (aOR) with 95% CI after adjusting for relevant known confounders. Findings: We enrolled 1,143 cases and 2,541 controls. The VE of full vaccination was 80% (95% CI: 73%-86%) with AZD1222/Covishield and 69% (95% CI: 54%-79%) with BBV152/Covaxin. The VE was highest for a gap of 6-8 weeks between two doses of AZD1222/Covishield (92%, 95% CI: 82%-96%) and BBV152/Covaxin (92%, 95% CI: 26%-99%). The VE estimates were similar against the Delta strain and sub-lineages. Interpretation: BBV152/Covaxin and AZD1222/Covishield were effective against severe COVID-19 among the Indian population during the period of dominance of highly transmissible Delta variant in second wave of pandemic. An escalation of two-dose coverage with COVID-19 vaccines is critical to control the pandemic in the country. Funding Information: Indian Council of Medical Research Declaration of Interests: None to declare. Ethics Approval Statement: We obtained written informed consent from all the participants or their legally authorized representatives. Study procedures were approved by the Institutional Human Ethics Committees of all participating institutions.

Context: Spirometry is an important tool to monitor treatment response in diseases such as chronic obstructive pulmonary disease and asthma. However, there is lack of evidence to support its application to evaluate response to chemotherapy in advanced lung cancer. It might be a useful adjunct to the imaging-based response evaluation which lacks functional assessment of lungs. Aims: The study was conducted to evaluate the change in spirometry in lung cancer patients after chemotherapy and to find its correlation with change in physical tumor size. Subjects and Methods: Sixty-two advanced lung cancer patients who were eligible for palliative chemotherapy were enrolled. Baseline tumor size evaluation using Response Evaluation Criteria in Solid Tumor (RECIST)-based scoring system, and spirometry was done. Four cycles of double agent (platinum doublets) chemotherapy were administered, after which treatment response was evaluated. Repeat spirometry was analyzed and correlated with changes in physical tumor size. Results: Twenty-five patients showed a response (all partial response) to four cycles of chemotherapy. Small cell carcinoma showed a better response rate than non-small cell carcinoma (78% vs. 39%). There was statistically significant improvement in forced expiratory volume in 1 (FEV1) (P = 0.01) and forced vital capacity (P = 0.03) in responders as compared to nonresponders. Change in FEV1 showed a statistically significant correlation with the change in tumor size (RECIST score) (r = –0.34; P = 0.04). Conclusions: Improvement in spirometry correlates with the tumor response as judged using RECIST criteria after chemotherapy. Further studies with bigger sample size are required to consolidate the results.

Establishing a diagnosis of melioidosis based on clinical grounds is difficult in hospitalized patients with sepsis or community acquired pneumonia (CAP). We aimed to ascertain the prevalence, clinico-epidemiological and laboratory profile of melioidosis in hospitalized patients with sepsis or CAP, and to evaluate the diagnostic utility of rapid lateral flow immunoassay (LFI) and PCR in comparison with culture. In all patients with sepsis or CAP, blood, sputum/throat swab, and urine sample were subjected to culture along with other samples based on clinical presentation. In addition, PCR assay targeting the type III secretion system 1 (TTS1) and LFI was performed. Thirty-three (33/196, 17%) out of the total 196 cases were diagnosed as melioidosis by culture. The prevalence of melioidosis in patients who had only sepsis without CAP, had both sepsis and CAP, had CAP without sepsis was 31% (26/84), 22 % (4/18) and 3%(3/94) respectively. All the LFI or PCR positive cases were culture positive from at least one or more samples (blood/sputum/urine/pus). The sensitivity, specificity, positive predictive value and negative predictive value of TTS1 PCR was 78% (18/23 melioidosis patients), 100% (34/34 non-melioidosis patients), 100% (18/18 melioidosis patients) and 87% (34/39 non-melioidosis patients). The sensitivity, specificity, positive predictive value and negative predictive value of Rapid LFI was 91% (21/23 melioidosis patients), 100% (22/22 non-melioidosis patients), 100% (21/21 melioidosis patients) and 91% (22/24 non-melioidosis patients). On sample wise stratification of LFI and TTS1 with respect to culture, plasma/serum samples showed the highest discordance by PCR (9/55, 16.3%) and LFI (11/35, 31.4%). The lowest discordance was noted in respiratory tract samples (2/32, 6.2%) by PCR and pus/body fluids samples (2/14, 14.2%) by LFI and these findings are in line with previous published literature. The clinical utility of PCR and LFI needs to be further validated in a large scale study for early diagnosis of septicaemic melioidosis.

ROS1-rearrangement occurs in 1-2% of non-small cell lung cancer (NSCLC). This mutation is predominantly seen in relatively young, non-smoker, female with adenocarcinoma. Association of pulmonary embolism with ROS1-rearranged NSCLC has been suggested. We report a case of a 22-year-old woman with ROS1-positive NSCLC and pulmonary embolism. This case possibly represents the youngest patient in the literature.

Endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) is routinely performed for diagnostic evaluation of mediastinal lymphadenopathy due to various etiologies with excellent sensitivity and specificity. Melioidosis can have atypical features like isolated mediastinal lymphadenopathy mimicking as tuberculosis or lymphoma. Differentiation of such atypical melioidosis presentation become difficult due to similar clinical, radiological and even similar EBUS lymph node characteristics. Role of EBUS TBNA in diagnosing melioidosis is under investigated and sparsely reported. We describe two cases of melioidosis diagnosed by point of care rapid lateral flow immunoassay antigen testing and culture of EBUS-TBNA samples from necrotic mediastinal lymph nodes.

Tubercular lymphadenitis (TBLA) contributes to 30-40% of extrapulmonary TB cases in the immunocompetent individuals and 40-50% in people with HIV. Current diagnostic methods for TBLA like Gene-Xpert or PCR are costly and conventional methods like fine needle aspiration cytology, histopathology lack sensitivity and specificity. Culture which is considered as gold standard require high turnaround time. Loop mediated isothermal amplification (LAMP) assay has been developed as a novel technique for nucleic acid amplification and has shown promising results in the diagnosis of pulmonary tuberculosis. Present study evaluated the Nu-LAMPTM TB Kit (RAS Life Sciences Pvt. Ltd, a bioMerieux group company) for diagnosis of TBLA comparing with conventional tests (cytology, ZN smear, culture). The sensitivity, specificity, PPV and NPV of LAMP assay was found to be 33.3%, 91.2%, 40% and 88.57% as compared to 100%, 76.5%, 42.9% and 100% of ZN staining and 100%, 73.5%, 40% and 100% of cytopathology. The low sensitivity of LAMP assay in the present study addresses the need for comparison and validation of the commercially available LAMP kits before used for patient diagnosis.

Melioidosis is an emerging infectious disease in India mostly reported from South-western coastal Karnataka and North-eastern Tamil Nadu. We speculate the existence of another major hidden focus in Odisha, one of the eastern coastal states. The clinico-epidemiological features of 47 culture-confirmed melioidosis at a tertiary care teaching hospital over a period of 2 years are reported. Septicaemia was the most common clinical presentation. Diabetes mellitus (DM) was present in 72.3% of our cases. The geo-climatic conditions of Odisha and other coastal states of India and the rise in the incidence of DM demand a nationwide surveillance of melioidosis and creation of melioidosis registry.

Introduction: The COVID-19 pandemic has caused unprecedented crisis in the care of non-Covid patients all across the globe and care for lung cancer patients is no exception Lung Cancer patients are at increased risks of COVID due to increased mortality from dual aggressive pathology in the lungs Our aim was to examine the impact of COVID-19 on lung cancer therapy and factors responsible delay in optimal care during the pandemic Methods: This study included all patients with a diagnosis of lung cancer being treated at our Institute, a tertiary level referral hospital in eastern part of India during on going pandemic Seven developed COVID-19, confirmed by RT-PCR method (Table 1) Results: The mean age of the patients was 49 years All the patients had metastatic lung cancer All males had history of smoking Hypertension was present in only one patient Four patients (57%) died from concomitant COVID-19 at our institution Three patients who recovered from COVID were stable One of them (positive for ROS1) was switched over to Crizotinib and other patient resumed chemotherapy only after he had recovered from COVID-19 Most of the patients acquired COVID-19 infection during the process of evaluatio/chemotherapy and that further delayed the treatment [Formula presented] Conclusion: The results were disappointing because more than half of lung cancer patients died due to COVID-19 The disease course of COVID-19 has been more severe in patients with lung cancers with Chemotherapy There have been delay in resuming treatment among survivors by few weeks Fear of aggressiveness of disease was the key factor for interruption or delay in chemotherapy Other variable factors like stage of cancer, palliative intent of chemotherapy, ECOG status were key determinants for interruption of treatment The decision to temporarily suspend chemotherapy while waiting for recovery from SARS-CoV-2 and then restart, was not easy due to the risk of cancer progression The findings amplify the importance of optimizing of lung cancer care in the context of the COVID-19 prevalence The decisions need to be taken on the basis of individual cases rather than rely on a generalized approach In resource limited country like India diverting the existing resources to an emergency leads to compromise of routine outpatient care, especially patients with chronic illness We need to be flexible in restarting of services guided by local COVID prevalence, while awaiting a definite management plan for COVID-19 Keywords: lung cancer, India, COVID-19, SARS-CoV-2

Melioidosis, caused by the environmental saprophyte, Burkholderia pseudomallei, is an important public health problem in Southeast Asia and Northern Australia. It is being increasingly reported from other parts, including India, China, and North and South America expanding the endemic zone of the disease. We report a case of systemic melioidosis in a 58-year-old diabetic, occupationally-unexposed male patient, who presented with chronic fever, sepsis, pneumonia, pleural effusion and subcutaneous abscess, was undiagnosed for long, misidentified as Pseudomonas aeruginosa infection elsewhere, but was saved due to correct identification of the etiologic agent and timely institution of appropriate therapy at our institute. A strong clinical and microbiological suspicion for melioidosis should be considered in the differential diagnosis of acute pyrexia of unknown origin, acute respiratory distress syndrome and acute onset of sepsis, especially in the tropics.

Pulmonary strongyloidiasis is an uncommon presentation of Strongyloides infection, usually seen in immunocompromised hosts. The manifestations are similar to that of acute exacerbation of chronic obstructive pulmonary disease (COPD). Therefore, the diagnosis of pulmonary strongyloidiasis could be challenging in a COPD patient, unless a high index of suspicion is maintained. Here, we present a case of Strongyloides hyperinfection in a COPD patient mimicking acute exacerbation, who was on chronic steroid therapy.

Background: Uncontrolled asthma is known to impair sleep and quality of life. However, influence of poor sleep quality on asthma control is little known. Objectives: To assess whether poor sleep quality is a predictor of uncontrolled asthma. Methods: Single-center cross-sectional study in adults (≥18 years) with physician diagnosed asthma of at least six months. Pittsburg Sleep Quality Index (PSQI) cut off ≥5 was considered as poor sleep. Asthma Control Questionnaire-6 (ACQ6, cut off ≥1.5) and Standardized Asthma-related Quality of Life Questionnaire (AQLQ-S) were used to assess asthma control and quality of life respectively. Chi Square test and logistic regression were performed as applicable. Relationships between PSQI, ACQ6 and AQLQ-S scores were assessed by Spearman correlation. Data was analysed using software ‘R’ with significance set at p Results: A total of 136 (64 males) patients [median age 39(IQR 26.75-47.25) years, mean BMI 24.72±3.93] were enrolled. The median PSQI and ACQ6 scores were 5 (IQR 3-7) and 1.33 (IQR 0.5-2.04) respectively. Mean AQLQ-S score was 5.25 ±1.03. Overall, 64 patients had uncontrolled asthma and 69 were poor sleepers. Poor sleep quality was associated with four times increased risk of uncontrolled asthma (OR 4.14, CI 2.02-8.48, p=0.0001). Further, 35% of controlled asthma patients reported poor sleep. The adjusted odds for uncontrolled asthma was 1.43 (p Conclusions: Poor sleep quality is independently associated with uncontrolled asthma and poor quality of life. Poor sleep is not uncommon among patients with controlled asthma.

A 32-year-old male heavy smoker presented to outside hospital with history of cough and shortness of breath for 20 days [...]

Introduction: COVID-19 pandemic has led to reconsider the traditional management approach in lung cancer Oral tyrosine kinase inhibitors (TKIs) are being preferred in oncogene addicted advanced non-Small Cell Lung Cancer Methods: A young never-smoker woman presented with left hilar mass with left pleural effusion in February 2020 There was an incidental detection of thrombus in right main and descending pulmonary artery She was diagnosed to have ROS1 rearranged advanced NSCLC with pulmonary embolism She was initiated on conventional chemotherapy with carboplatin and pemetrexed along with anticoagulation After fourth cycle of chemotherapy, although there was clinical improvement attributed to reduction of amount of effusion and disappearance thrombus, RECIST 1 1 criteria suggested the progression of disease in view of appearance of adrenal metastasis Meanwhile, she had a history of high risk exposure with a patient of COVID- 19 in July 2020 Although she was asymptomatic, RT- PCR for SARS-COV2 came out to be positive Results: She remained asymptomatic for next 10 days during hospitalization Then she was started on Crizotinib and was discharged with advice on further follow up Conclusion: Although patients on cancer chemotherapy are at high risk of severe COVID-19 diseases, asymptomatic cases can happen The patients preferably should be shifted to or started on oral TKIs as per available expert recommendations Keywords: ROS1, COVID-19, TKI

Statement of the Problem: Healthcare workers (HCW) are the most vulnerable group for contracting SARS-CoV-2. Assessment of seroprevalence of SARS-CoV-2 antibodies among HCW, thus can provide important data on pathogen exposure, infectivity, and adherence to personal protective equipment (PPE). The present study aimed at assessing SARS-CoV-2 seroprevalence among HCW and exploring associations with demographics, category of exposure to COVID-19 patients, preventive measures taken and relation with COVID-19 symptoms. Method of Study: HCWs with a minimum gap 2 weeks from last duty were eligible to participate in the study. The enrolled HCW were categorized into high-risk and low-risk category based on work in COVID-19 areas. HCWs SARS-CoV-2 specific IgG and IgM antibodies were detected using rapid immunochromatography test. Results: Out of 821 randomly selected HCWs, either IgM or IgG antibody was detected in 32 HCWs (32/821, 3.9%). Only IgM antibodies were detected in 14 (1.7%), only IgG was detected in 9 (1.0%), and both IgM and IgG antibodies were present in 9 HCWs. Seropositivity was significantly higher in high-risk category (5.7% vs. 2.2.%), HCWs who ever had COVID-19 related symptoms in last 3 months (5.6% vs. 2.8%), and those who had earlier tested positive for SARS-CoV-2 with real-time reverse transcriptase PCR (36.6% vs. 3.5%). Seroprevalence was highest (6.9%) among housekeeping and sanitation staff. Conclusions: Overall, low seroprevalence of SARS-CoV-2 antibodies in our HCWs is an indicator of effective infection control practice. HCW posted in dedicated COVID ward need more stringent implementation of infection prevention measures.

A 65-year-old woman, a non-smoker, presented to the pulmonary medicine outpatient department with chest pain, mild dyspnoea, right side neck swelling and mild facial puffiness. The cervical swelling was soft, non-tender and fluctuant on palpation. Multimodality imaging revealed a large, thin-walled cervicomediastinal cystic lesion with septations, haemorrhage, septal calcification and without any solid component. Image-guided fine-needle aspiration cytology from the septa with immunocytochemistry helped to establish the thymic origin and benign nature of the cyst preoperatively and differentiate it from cystic thymoma, lymphangioma, thymic carcinoma or lymphoma with confidence. As the haemorrhage resolved, the size of the swelling was significantly reduced, and the patient became asymptomatic due to which she deferred surgery but remained on close follow-up and was doing well. Thymic cysts can occur in a cervicomediastinal location, rare in elderly age, usually asymptomatic and clinically apparent when intracystic haemorrhage leads to an increase in size and chest pain.

A 39-year-old never smoker male with a 3-month history of progressive dyspnea was found to have a heterogeneously enhancing right lung mass with multiple [...]

Contents: Executive Summary Introduction Methodology Definition, Epidemiology and Risk Factors Diagnosis of Asthma Management of Stable Asthma Management of Acute Exacerbations of Asthma Miscellaneous Issues in Asthma Management

Tuberculous infection of the tracheobronchial tree confirmed by microbiological or histopathological evidence with or without parenchymal involvement is known as endobronchial tuberculosis. Chronic cough is the predominant symptom. Expectorated sputum examination for acid fast bacilli is often negative leading to delay in diagnosis. Therefore, bronchoscopy is crucial for early diagnosis and evaluation of the extent of disease. Bronchostenosis is a significant complication of endobronchial tuberculosis that may be present at the time of diagnosis or develops during the course of treatment. Previously, corticosteroids have been used along with antitubercular therapy to prevent or reduce the extent of bronchostenosis; however, their role is debatable as bronchostenosis often develops despite the use of corticosteroids. Furthermore, the duration of treatment varied from 6–9 months of daily therapy in previous series and little is known about efficacy of intermittent antituberculous therapy. Here we report two cases of actively caseating endobronchial tuberculosis successfully managed with six months of intermittent oral antitubercular therapy without corticosteroids.

A 40-year-old male presented with progressive breathlessness and hoarseness of voice. He denied any history of chest pain, cough, haemoptysis, palpitations or paroxysmal nocturnal dyspnoea. He was a smoker with 10 pack-year of smoking. His medical illness includes long-standing hypertension of 10 years duration controlled with oral amlodipine and atenolol. Previous echocardiography showed dilated and hypertrophied left ventricle with severe systolic dysfunction. At presentation, he was fully conscious with vitals as follows: heart rate 124/min, respiratory rate 34/min and blood pressure 110/70 mm Hg. All peripheral pulses were well felt. Chest examination revealed diminished movement of left hemithorax, reduced vocal resonance and breath sound with shift of mediastinum to right. Posteroanterior chest radiograph showed an opaque left hemithorax and a large retrocardiac opacity (arrows) with contralateral shift of mediastinum (figure 1A). Ultrasonography of thorax showed a large mixed echogenic lesion …

Abnormal bronchus arising directly from the trachea or the main bronchus is a rare developmental anomaly of the tracheobronchial tree. In general, tracheal bronchus has been reported in less than 1% of adult patients undergoing bronchoscopy with a male predominance. Tracheal bronchus is classified as—‘displaced’ and ‘supernumerary’, the former being the most common type reported. Most patients are asymptomatic; however, cases presenting with cough, haemoptysis or recurrent lung infections are not uncommon. The diagnosis is usually made through computed tomography or bronchoscopy. Awareness of this anomaly may help in timely identification or prevention of perioperative complications during general anaesthesia or resectional thoracic surgery. Herein we report a case of right-sided displaced tracheal bronchus in an adult female presenting with recurrent haemoptysis.

Pulmonary alveolar microlithiasis (PAM) is a rare, chronic lung disease with bilateral intra-alveolar calcium and phosphate deposition throughout the lung parenchyma with predominance to lower and midzone. Although, etiology and pathogenesis of PAM is not fully understood, the mutation in SLC34A2 gene that encodes a sodium-phosphate co-transporter in alveolar type II cells resulting in the accumulation and forming of microliths rich in calcium phosphate (due to impaired clearance) are considered to be the cause of the disease. Chest radiograph and high-resolution CT of thorax are nearly pathognomonic for diagnosing PAM. HRCT demonstrates diffuse micronodules showing slight perilobular predominance resulting in calcification of interlobular septa. Patients with PAM are asymptomatic till development of hypoxemia and cor-pulmonale. No therapy has been proven to be beneficial except lung transplantation.

Introduction: Prevalence of tobacco smoking continue to increase in developing nations despite huge economic loss, high morbidity, mortality or regulatory acts to curb tobacco smoking. Aims and objectives: To assess level of exposure among tobacco smokers, understand their social background, behaviour pattern, awareness regarding risks of smoking and feasibility of introducing early smoking prevention programs. Methods: A cross-sectional study where adult patients with respiratory ailments attending Pulmonary Medicine department of a premier tertiary level hospital were interviewed using a structured questionnaire including parameters like socio-demographic data, awareness about hazards of smoking, willingness and benefits of quitting smoking. All required investigations were done, the data tabulated and analysed statistically. Results: Among the 58 patients enrolled, mean age was 53.5 years (SD:13.9). Education level of the subjects were school drop outs(29.3%), 10 th standard(27.6%), graduates(19%) and illiterate(12.1%). 53.4% were current smokers, 48% mild smokers, 12.1% heavy smokers. Among 40 regular smokers, 32.5% became regular at >22 years, 30% at 18-21 and 25% at 14-17 years of age. 95% of smokers knew it is harmful, 32.7% admitted they never bothered to read the statutory warning, 69% understood the meaning of the statutory warning, 25.8% did not have any knowledge about passive smoking. Associated respiratory ailments were COPD(63.7%), Asthma(10.3%), tuberculosis(8.6%), lung cancer(1.7%). Conclusion: Adolescents are most vulnerable to fall prey to clutches of tobacco smoking and should be primarily targeted for early smoking prevention programs including raising the education level.

Chilaiditi sign is the peculiar radiographic presentation of interposition of colon between diaphragm and liver. When associated with symptomatology, it is called as chilaiditi’s syndrome. Though rare, respiratory symptoms may be present. In such cases, it becomes difficult to determine if the symptomatology is due to the syndrome only, or there is some underlying lung involvement, until this is specifically considered in the differential diagnosis. We present a male patient, where thorough investigations revealed Interstitial Lung Disease (ILD), along with Chilaiditi sign on chest radiograph. Respiratory symptomatology responded partially to the management of underlying ILD. It is left for discussion, whether the Chilaiditi syndrome was also contributing to the overall clinical presentation or the respiratory complaints were solely due to ILD and Chilaiditi sign was an incidental finding.

Background: The World Health Organization-Government of India (WHO-GOI) Guidelines - 2003 for management of chronic obstructive pulmonary diseases (COPD) is a consensus statement. However, the outcome and impact of its implementation on quality of life (QOL) among COPD patients has not been studied so far. Materials and Methods: The patients were randomized to intervention group (n = 50) and control group (n = 40). All were treated and followed up for 6 months. A pulmonary physician reviewed patients of both the groups, at least 3 times in 6 months period. St. George's Respiratory Questionnaire was measured at baseline and at 6 months. Patients in control group visited the center on a need to basis and were prescribed conventional treatment by the doctor on duty. Results: Forty-two patients in the intervention group and 32 in the control group completed 3 visits over the period of 6 months and were included in analysis. The severity as per the guidelines was moderate in 74% and severe in 26% in intervention group while it was moderate in 64% and severe in 36% cases in control group. Follow-up QOL scores were significantly better as compared with baseline values ( P< 0.001).The QOL of the patients treated according to the guidelines were significantly better ( P< 0.001) than those in the control group with conventional treatment. Conclusion: The consensus derived recommendations of WHO-GOI Guidelines for COPD-2003 are beneficial for management of COPD patients over conventional management.

Tagami et al. [1], in their retrospective analysis, have contributed to further understanding of the use of corticosteroids in severe community-acquired pneumonia (CAP) and put forth an inference on the current dispute. Some issues, however, need further discussion. Defining low-dose corticosteroid in severe community-acquired pneumonia

Obstructive sleep apnea (OSA) and obstructive sleep apnea syndrome (OSAS) are subsets of sleep-disordered breathing. Awareness about OSA and its consequences among the general public as well as the majority of primary care physicians across India is poor. This necessitated the development of the Indian initiative on obstructive sleep apnea (INOSA) guidelines under the auspices of Department of Health Research, Ministry of Health and Family Welfare, Government of India. OSA is the occurrence of an average five or more episodes of obstructive respiratory events per hour of sleep with either sleep-related symptoms or co-morbidities or ≥15 such episodes without any sleep-related symptoms or co-morbidities. OSAS is defined as OSA associated with daytime symptoms, most often excessive sleepiness. Patients undergoing routine health check-up with snoring, daytime sleepiness, obesity, hypertension, motor vehicular accidents, and high-risk cases should undergo a comprehensive sleep evaluation. Medical examiners evaluating drivers, air pilots, railway drivers, and heavy machinery workers should be educated about OSA and should comprehensively evaluate applicants for OSA. Those suspected to have OSA on comprehensive sleep evaluation should be referred for a sleep study. Supervised overnight polysomnography is the "gold standard" for evaluation of OSA. Positive airway pressure (PAP) therapy is the mainstay of treatment of OSA. Oral appliances (OA) are indicated for use in patients with mild to moderate OSA who prefer OA to PAP, or who do not respond to PAP or who fail treatment attempts with PAP or behavioral measures. Surgical treatment is recommended in patients who have failed or are intolerant to PAP therapy.

Desmoid tumor is a rare, benign soft tissue tumor having potential for local invasion. It commonly arises in abdominal wall, presenting as a palpable mass. We describe a case of thoracic desmoid tumor in a middle aged male arising from the chest wall. Unlike the usual presentation, two separate non-palpable tumor masses protruded into left thoracic cavity mimicking lung carcinoma. The patient underwent successful complete surgical excision of the tumor. Such tumors, being rare, may pose diagnostic problems if not considered in the initial work up.

Vorselaars et al. [1] have shown infliximab, a monoclonal antibody against tumour necrosis factor (TNF), to be an effective agent in the treatment of refractory sarcoidosis. We put forth some issues that are worth discussing among scientific societies. Diagnosis and treatment of FDG PET-positive sarcoidosis with infliximab needs caution, especially in TB endemic areas

Hughes et al. [1] should be commended for their interesting short study on evaluating the efficacy of linezolid in drug-resistant tuberculosis (TB). However, there are some points of concern that need to be discussed. A recent systematic review and meta-analysis cautions the use of linezolid in multidrug-resistant (MDR) TB because of the frequency and severity of adverse events ( i.e. peripheral and optic neuropathy, myelosuppression and gastrointestinal disorders), despite its excellent efficacy. This robust study recommends the use of linezolid in only severe and difficult-to-treat cases but under strict supervision [2]. The use of linezolid should be preserved for XDR-TB and complicated drug-resistant-TB only

We present a case of severe H1N1 influenza with hypoxemic acute respiratory failure necessitating mechanical ventilation benefited from noninvasive positive pressure ventilation (NIPPV). The NIPPV may be of great use in treating patients with H1N1-related acute respiratory distress syndrome in a resource poor setting or when invasive ventilator is unavailable.

To the Editor: We read with interest the study by Cavallazzi et al . [1] in which authors have devised a subset of risk factors that can efficiently predict pulmonary tuberculosis (TB) in patients of community-acquired pneumonia (CAP). Although they have improvised upon existing Centers for Disease Control and Prevention (CDC) list of risk factors, the study requires discussion regarding its practical …