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Mycobacterium tuberculosis has been known to infect humans for eons. It is an airborne infectious disease transmitted through droplet nuclei of 1 to 5 µm in diameter. Historically, tuberculosis (TB) was considered a distinct condition characterized by TB infection and active TB disease. However, recently, the concept of a dynamic spectrum of infection has emerged, wherein the pathogen is initially eradicated by the innate or adaptive immune system, either in conjunction with or independently of T cell priming. Other categories within this spectrum include TB infection, incipient TB, subclinical TB, and active TB disease. Various host- and pathogen-related factors influence these categories. Furthermore, subclinical TB can facilitate the spread of infection within the community. Due to its asymptomatic nature, there is a risk of delayed diagnosis, and some patients may remain undiagnosed. Individuals with subclinical TB may stay in this stage for an indeterminate period without progressing to active TB disease, and some may even experience regression. Early diagnosis and treatment of TB are essential to meet the 2035 targets outlined in the end-TB strategy. This strategy should also include incipient and subclinical TB. This review will focus on the definition, natural history, burden, trajectory, transmissibility, detection, and management of early-stage TB.

Physical examination is an important ritual of bedside medicine that establishes a strong bond between the patient and the physician. It provides practice to acquire important diagnostic skills. A poorly executed bedside examination may result in the wrong diagnosis and adverse outcomes. However, the ritual of obtaining a patient’s history and performing a good clinical examination is declining globally. Even the quality of clinical examination skills is declining. One reason may be the short time spent by physicians at the bedside of patients. In addition, due to the substantial technological advancement, physicians often rely more on technology and consider clinical examinations less relevant. In resource-limited settings, thorough history-taking and physical examinations should always be prioritized. An important aspect of respiratory auscultation is the auscultation over the chest wall to detect abnormalities in the transmission of voice-generated sounds, which may provide an important diagnostic clue. Laënnec originally described in detail three types of voice-generated sounds and named them bronchophonism, pectoriloquism, and egophonism. Subsequently, they are known as bronchophony, whispering pectoriloquy, and egophony. A recent variant of egophony is “E-to-A” changes. We searched PubMed, EMBASE, and the CINAHL from inception to March 2018. We used the following search terms: vocal resonance, bronchophony, egophony, whispering pectoriloquy, auscultation, etc. All types of studies were chosen. This review will narrate the physics of sound waves, the types of vocal resonance, the mechanisms of vocal resonance, the methods to elicit them, and the accuracy of vocal resonance.

Pulmonary alveolar microlithiasis (PAM) is a rare autosomal recessive disease characterised by the deposition of calcium phosphate microliths in the alveoli. PAM has been reported in all continents and there is often a familial history. There is clinical-radiological dissociation as there is often a paucity of symptoms in contrast to the imaging findings. Patients often remain asymptomatic until the third or fourth decade of life, and dyspnea is the most common symptom. PAM is caused by a mutation within the solute carrier family 34 member 2 gene (the SLC34A2 gene) located on chromosome 4p15.2, which encodes a sodium/phosphate co-transporter. The imaging appearance of the disease is quite pathognomic with the high-resolution computed tomography (HRCT) demonstrating a diffuse micronodular appearance. Transbronchial lung biopsy also confirms the diagnosis. There is no effective therapy at present except lung transplantation. We herein, present a case of PAM along with clinical history, imaging study, histopathological study and genetic study of a 43-year-old female adult patient along with genetic analysis.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a highly transmissible and pathogenic coronavirus responsible for the pandemic coronavirus disease 19 (COVID-19). It has significant impact on human health and public safety along with negative social and economic consequences. Vaccination against SARS-CoV-2 is likely the most effective approach to sustainably control the global COVID-19 pandemic. Vaccination is highly effective in reducing the risk of severe COVID-19 disease. Mass-scale vaccination will help us in attaining herd immunity and will lessen the negative impact of the disease on public health, social and economic conditions. The present pandemic stimulated the development of several effective vaccines based on different platforms. Although the vaccine is safe and efficacious, rare cases of thrombosis and thrombocytopenia following the use of vaccination with the ChAdOx1 CoV-19 vaccine (AstraZeneca, University of Oxford, and Serum Institute of India) or the Ad26.COV2.S vaccine (Janssen/Johnson & Johnson) have been reported globally. This review focussed on the definition, epidemiology, pathogenesis, clinical features, diagnosis, and management of vaccine associated thrombosis.

Oxygen is probably the most commonly prescribed drug in the emergency setting and is a life-saving modality as well. However, like any other drug, oxygen therapy may also lead to various adverse effects. Patients with chronic obstructive pulmonary disease (COPD) may develop hypercapnia during supplemental oxygen therapy, particularly if uncontrolled. The risk of hypercapnia is not restricted to COPD only; it has also been reported in patients with morbid obesity, asthma, cystic fibrosis, chest wall skeletal deformities, bronchiectasis, chest wall deformities, or neuromuscular disorders. However, the risk of hypercapnia should not be a deterrent to oxygen therapy in hypoxemic patients with chronic lung diseases, as hypoxemia may lead to life-threatening cardiovascular complications. Various mechanisms leading to the development of oxygen-induced hypercapnia are the abolition of ‘hypoxic drive’, loss of hypoxic vasoconstriction and absorption atelectasis leading to an increase in dead-space ventilation and Haldane effect. The international guideline recommends a target oxygen saturation of 88% to 92% in patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD) and other chronic lung diseases at risk of hypercapnia. Oxygen should be administered only when oxygen saturation is below 88%. We searched PubMed, EMBASE, and the CINAHL from inception to June 2022. We used the following search terms: “Hypercapnia”, “Oxygen therapy in COPD”, “Oxygen-associated hypercapnia”, “oxygen therapy”, and “Hypoxic drive”. All types of study are selected. This review will focus on the physiological mechanisms of oxygen-induced hypercapnia and its clinical implications.

The flow volume loop (FVL) is a graphic display of airflow against lung volumes at different levels obtained during the maximum inspiratory and expiratory maneuver. It is a simple and reproducible method of lung function assessment. A narrative review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. PubMed, EMBASE, Ovid MEDLINE and CINAHL databases were queried and reviewed for studies pertinent to the various FVLs abnormalities and their mechanisms from January 2020 to December 2020. We used the following search terms; flow-volume loop, upper airway obstruction, Obstructive airway disease, and spirometry. Assessing the shape of the flow-volume loop is particularly helpful in diagnosing and localizing upper airway obstruction. They are also helpful in identifying bronchodilator response to treatment. Characteristic FVLs is also seen in patients with obstructive or restrictive lung disorders. Spirometry should be interpreted using the absolute values for flows and volumes as well as the flow volume and volume time curves.

PURPOSE: The aim of the current work was to report the effect of imatinib on pregnancy in patients with chronic myeloid leukemia (CML). METHODS: Data were collected between January 1998 and December 2014. One hundred four patients met inclusion criteria, and we report the results of 104 pregnancies—conceived by the participant or partner—while being on imatinib therapy for CML. RESULTS: Fifty-eight patients were male and 46 were female. Eighty-three patients, 20 patients, and one patient were had CML in the chronic phase, accelerated phase, or blast phase, respectively. Of 46 female patients, 21 underwent abortion (spontaneous, n = 36.9; elective termination, n = 8.6%). In the case of full-term pregnancy in the female partners of male patients with CML, all outcomes were uneventful. Of 46 female patients, 25 had full-term pregnancy outcomes. During the pre–imatinib era (total n = 6), patients were treated with hydroxyurea, interferon-alpha, and therapeutic leukapheresis. A total 10 of 19 pregnant patients continued on imatinib until their delivery and experienced the following outcomes: normal full-term deliveries (n = 7), preterm delivery (n = 1), omphalocele (n = 1), and craniosynostosis (n = 1). Of those who discontinued imatinib after counseling (n = 9), eight patients had full-term normal delivery, of which two patients required leukapheresis and one patient expired. All patients who continued on imatinib while pregnant were in complete cytogenetic response and major molecular response (MMR) before pregnancy, during pregnancy, and postpregnancy. Of nine patients who discontinued imatinib, two lost MMR during the third trimester and all of these patients were in complete cytogenetic response and MMR before pregnancy. CONCLUSION: It is clear that there is no standard of care for the best treatment of CML in the case of pregnancy. Interferon and/or leukapheresis will be included as treatment options. Patients can have normal pregnancies even with the administration of imatinib at the risk of congenital anomalies, intervention for which can be done after birth.

Introduction: To study the prevalence of anxiety and depression in stable COPD patients. Methodology: 100patients of stable COPD were assessed to look for the presence of anxiety and depression using beck anxiety inventory (BAI) and patient health questionnaire (PHQ-9). Patients already on treatment forpsychiatric illnesses were excluded from the study. Patients with total score above cut off value (BAI >7 ORPHQ-9 >4), were assessed in the psychiatry department. Quantitative data was compiled and statistical analysis was done. Results: Among study population 68% were males, 62% were in the age group of 60-80years, 83 % were ex smokers and 92 % of them were exposed to indoor air pollution (chullahs). It was found that 64 % of the study population had psychiatric morbidity out of which 42% had mixed anxiety and depressive symptoms. Psychiatric symptoms were more prevalent in female patients (97%, P value is0.003), and in patients who had more severe disease (P value is 0.04), 6 minute walk distance < 300 m (P value is 0.00001), percentage of desaturatoin> 3% after 6 M.W (P value is 0.0001) and Smoking Index >400.Smoking status and 6 minute walk distance were independently associated with the development of anxiety and depression with significant P values in stable COPD patients. Conclusion: Anxiety and depression are common psychiatric co-morbidities associated with COPD patients. Early diagnosis and proper management of COPD and timely evaluation for psychiatric illnesses is essential for the better outcomes in COPD patients.

Background: Ventilator-associated pneumonia (VAP) is the most common nosocomial infection diagnosed in the intensive care unit (ICU). The aim is to determine the incidence, bacteriology and resistant pattern and 28 days mortality in intensive care unit. Methods: This prospective study was conducted in intensive care unitfrom July 2017 through June 2018. All the patients who were on mechanical ventilation for >48 h in the ICU during the study period were enrolled. VAP was diagnosed according to the Centre for Disease Control (CDC) criteria. Fisher's exact test was applied to compare two or more set of variables.P-value less than 0.05 was considered to be statistically significant. Results: A total of 117 patients were included in the study and VAP developed in 49 patients with an incidence of VAP 0.42% episodes of infection/1000 mechanical ventilation days(95% Confidence Interval: 0.32 to 0.514).These were predominantly caused by Gram-negative organisms and the most common organism isolated was Acinetobacter baumanii(12 isolates,40%). Acinetobacter baumanii infection was associated with prolonged ICU stay(P value 0.009).Colistin was the most effective drug in our study and found to be effective in >90% of the patients. The overall mortality of VAP patients in our study was 36.7%. Patients with underlying diabetes mellitus and hypertension had adverse outcome in comparison to the patients without underlying comorbidity (P value=0.017). Conclusions: VAP continues to be a major threat to patients who are admitted for mechanical ventilation into the critical care unit, emphasizing the urgent need for infection control measures.

The enduring epidemic outbreak which started in Wuhan city of China, in December 2019 caused by the 2019 novel coronavirus (COVID- 19) or the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has created a dangerous and deadly Public Health disaster of International apprehension, with cases confirmed in several countries. This novel community health trouble is frightening the universe with clinical, psychological, emotional, collapse of health system and economical slowdown in each and every part of the world infecting nearly 200 countries. A highly virulent and pathogenic COVID-19 viral infection with incubation period ranging from two to fourteen days, transmitted by breathing of infected droplets or contact with infected droplets, belongs to the genus Coronavirus with its high mutation rate in the Coronaviridae. The likely probable primary reservoir could be bats, because genomic analysis discovered that SARSCoV-2 is phylogenetically interrelated to SARS-like bat viruses. The transitional resource of origin and transfer to humans is not known, however, the rapidly developing pandemic has confirmed human to human transfer. Approximately 1,016,128 reported cases, 211,615 recovered cases and 53,069 deaths of COVID-2019 have been reported to date (April 2, 2020). The symptoms vary from asymptomatic, low grade pyrexia, dry cough, sore throat, breathlessness, tiredness, body aches, fatigue, myalgia, nausea, vomiting, diarrhea, to severe consolidation and pneumonia, acute respiratory distress syndrome (ARDS) and multiple organ dysfunction leading to death with case fatality rate ranging from 2 to 3%.

We reviewed the various physical signs of chronic obstructive pulmonary disease, their pathogenesis, and clinical importance. We searched PubMed, EMBASE, and the CINAHL from inception to March 2018. We used the following search terms: chronic obstructive pulmonary disease, physical examination, purse-lip breathing, breath sound intensity, forced expiratory time, abdominal paradox, Hoover's sign, barrel-shaped chest, accessory muscle use, etc. All types of studies were chosen. Globally, history taking and clinical examination of the patients is on the wane. One reason can be a significant development in the field of medical technology, resulting in overreliance on sophisticated diagnostic machines, investigative procedures, and medical tests as first-line modalities of patient's management. In resource-constrained countries, detailed history taking and physical examination should be emphasized as one of the important modalities in patient's diagnosis and management. Declining bedside skills and clinical aptitude among the physician is indeed a concern nowadays. Physical diagnosis of chronic obstructive pulmonary disease (COPD) is the quickest and reliable modalities that can lead to early diagnosis and management of COPD patients. Bedside elicitation of physical signs should always be the starting point for any diagnosis and therapeutic approach.

Aim: The Objectives of our study were to study the clinical profile and microbiological etiology of AE-COPD. Methods: It was a hospital-based cross-sectional study, conducted in a tertiary care center and included patients hospitalized with a principal diagnosis of AE-COPD. Diagnosis of COPD was based on the GOLD guidelines. Detailed history, physical examination, sputum microbiology and blood investigations were recorded for all patients. All statistical analyses were done using Epi info 7.2. Results: Mean age of the patients was 66.9 years. Majority of the patients (66) were ex-smokers, 26 were current- and 8 were never-smokers. One-third of the patients were frequent exacerbators. Most common co-morbidity was hypertension (25%) followed by diabetes (10%). Increased dyspnea was seen in all the patients, followed by increased quantity of sputum in 56. The most common clinical findings were use of accessory muscles of respiration in 92 patients, followed by crackles (84) and decreased breath sound intensity (62). Majority of the exacerbations (55%) were non-infectious, followed by 33% bacterial and 12% viral exacerbations. The most common isolated bacteria were Streptococcus pneumoniae (31%), Pseudomonas (27%) and Klebsiella (12%). Conclusion: This study shows the common risk factors and clinical features presented by COPD patients hospitalized with severe exacerbation. Majority of the exacerbations were non-infectious, warranting further studies to determine the environmental factors. Although one-third of the exacerbations were bacterial, viruses were important etiological agents.

Skin metastases from colorectal carcinoma are rare and signal advanced disease. Skin metastasis refers to growth of cancer cells in the skin originating from an internal cancer. In most cases, cutaneous metastasis develops after the initial diagnosis of the primary internal malignancy and late in the course of the disease. In very rare cases, skin metastasis may occur at the same time or before the primary cancer has been discovered and may be the prompt for further thorough investigation. The incidence of skin metastasis varies but is somewhere between 3-10% in patients with a primary malignant tumor. Most common ones are melanoma (45%), breast cancer (30%), nasal sinus cancers (20%), cancer of the larynx and cancer of the oral cavity (12%) cases. Here we present a case of 39-year-old man presented to us with multiple subcutaneous lesions over the chest and forehead. Fine needle aspiration cytology of skin nodules revealed metastatic adenocarcinoma features. Further imaging of the abdomen with computed tomography (CT) revealed circumferential narrowing of caecum and ascending colon. The patient was managed with palliative right hemicolectomy in view of constipation and palliative chemotherapy as systemic treatment. An extensive review of the English literature did not reveal extensive data on metastatic subcutaneous nodules leading to diagnosis of colon cancer.

Introduction: To determine whether Computed Tomography Perfusion (CTP) can predict treatment response and prognosis in non-small cell lung cancers (NSCLC). To determine which one of the perfusion parameter correlated best with treatment outcome. Methods: Sixteen patients with NSCLC underwent CTP before and after completion of chemo-radiotherapy. Patients with complete and partial response were grouped as responders and patients with stable and progressive disease were grouped as non-responders. Pre and post-treatment whole tumour perfusion parameters (blood flow - BF, blood volume - BV, mean transit time - MTT and permeability surface area product - PS) were compared between responders and non-responders. Results: Responders had higher baseline BF and PS values than non-responders; P = 0.047, 0.028 respectively. On 1 year follow up, patients with even 2.65% increase in PS value from baseline developed metastasis while patients with decrease in PS value by 24% did not develop metastasis (P = 0.05). Greater decrease in BF values (17%) were noted among responders than non-responders (2.4%) following chemoradiation, though the results were not statistically significant (P > 0.05). Conclusions: Tumours with higher baseline BF and PS respond well to chemo-radiation. Changes in the PS values can predict the development of metastasis and hence, the long term outcome.

Immunotherapy is the treatment that either boosts the patient’s immune system or uses human-made versions of the normal parts of the immune system to kill lymphoma cells or slow their growth. A forty-eight-year-old lady with neck nodes, axillary nodes, weight loss and fever diagnosed to have Diffuse Large B-Cell Lymphoma (DLBCL) in December 2009 was treated with 6 cycles of R-CHOP, and her treatment was completed in May 2010. After 2 years in July 2012, the patient developed similar symptoms and received salvage chemotherapy with R-DHAP, and her treatment was completed in January 2013. After one and a half years, in August 2014, the patient again had relapsed DLBCL. She was treated with R-ICE 4-cycles and rendered disease-free following allogeneic HSCT in June 2015. But in December 2016, the patient again developed isolated axillary lymphadenopathy and relapsed DLBCL was confirmed by HPR and IHC. This time, the patient was unwilling to go on chemotherapy, but after counselling about the new drug, Nivolumab, she became convinced, and her treatment was started with 3mg per kg every 2 weeks. After 4 cycles, she had a complete response and is now being treated with the same treatment without any symptoms of the disease or any adverse drug reactions. Nivolumab was well tolerated and exhibited antitumor activity in extensively pretreated patients with relapsed or refractory B- cell lymphomas. Additional studies are ongoing to learn more about the use of Nivolumab in these diseases.

Oxygen is an essential element for life and without oxygen humans can survive for few minutes only. There should be a balance between oxygen demand and delivery in order to maintain homeostasis within the body. The two main organ systems responsible for oxygen delivery in the body and maintaining homeostasis are respiratory and cardiovascular system. Abnormal function of any of these two would lead to the development of hypoxemia and its detrimental consequences. There are various mechanisms of hypoxemia but ventilation/perfusion mismatch is the most common underlying mechanism of hypoxemia. The present review will focus on definition, various causes, mechanisms, and approach of hypoxemia in human.

Background: Chronic obstructive pulmonary disease (COPD) is a lifestyle-related chronic inflammatory pulmonary disease and a major cause of morbidity and mortality globally. Osteoporosis and osteopenia are common observations in COPD and degree of the loss of bone mineral density (BMD) has been found to be proportionate to the severity of the disease. Objectives: Our objective was to study the prevalence of osteoporosis and osteopenia in stable COPD patients in Indian Sub-Himalayan population. Materials and Methods: This study was performed on 84 patients of COPD attending as outpatient in the Pulmonary Medicine Department after application of inclusion and exclusion criteria. A control group of 60 healthy controls was selected for comparison with COPD group. Spirometry was done on patients to stage the severity of COPD according to global initiative for chronic obstructive lung disease criteria. Dual-energy X-ray absorptiometry scan of the lumbar spine was done using bone densitometer to determine the severity of reduced BMD. The patients were categorized according to the World Health Organization criterion for definition of reduced BMD. Results: In the present study, a total of 45.2% patients had osteoporosis, 41.6% patients had osteopenia while the rest 13% patients had normal bone density in the COPD group. The prevalence of low bone density was about 4 times higher in COPD group as compared to control group. There were 15.48 times higher chances of low BMD in COPD patients as compared to healthy controls. Conclusions: Reduced BMD is a common comorbid entity in COPD patients which leads to increase in bone fragility and susceptibility to fracture. It is recommended that all the patients with COPD should be screened for osteoporosis to initiate the treatment for the disorder before they develop fractures.

Introduction: Cholelithiasis and asymptomatic gallstones may produce pathological changes like hyperplasia and metaplasia of the gall bladder mucosal epithelium. It has been suggested that metaplastic epithelium is more susceptible to malignant transformation than the normal mucosa and the intestinal metaplasia-dysplasia-carcinoma sequence exists in the gall bladder. So, it is essential to detect metaplastic lesions of gall bladder early and mucin histochemistry study may be useful in this regard. Aim: To find out if mucin histochemistry can be used for early detection of metaplastic lesions of gall bladder as metaplastic epithelium is more prone to malignant transformation. Materials and Methods: A total of 1153 formalin-fixed paraffinembedded surgically resected gallbladder tissue samples were sectioned. All sections were stained with HaematoxylinEosin (HE), Alcian Blue (AB) and Periodic Acid-Schiff (PAS) stain. Results: A total of 1153 cholecystectomy cases were observed. Maximum cases were of chronic cholecystitis with gall stones (841 cases). Metaplasia was found in 201 out of 1153 cases. Mucin histochemistry in metaplastic group showed only PAS positivity in 52 cases (neutral mucin), both PAS and AB positivity in 122 cases (acidic mucin) and only AB positivity in 27 cases (acidic mucin). Conclusion: The gastric and intestinal metaplasia showed positivity more with acidic mucin than neutral mucin. Study of mucin histochemistry in metaplastic cases can lead to early detection and early diagnosis of carcinoma gallbladder.

Cystic echinococcosis (CE) is a zoonotic parasitic disease caused by the larval stages of the cestode Echinococcus granulosus. Worldwide, pulmonary hydatid cyst is a significant problem medically, socially, and economically. Surgery is the definitive therapy of pulmonary hydatidosis. Benzimidazoles may be considered in patients with a surgical contraindication. This review will focus on pathogenesis, lifecycle, clinical features, and management of pulmonary hydatid disease.

Auscultation of the lung is an important part of the respiratory examination and is helpful in diagnosing various respiratory disorders. Auscultation assesses airflow through the trachea-bronchial tree. It is important to distinguish normal respiratory sounds from abnormal ones for example crackles, wheezes, and pleural rub in order to make correct diagnosis. It is necessary to understand the underlying pathophysiology of various lung sounds generation for better understanding of disease processes. Bedside teaching should be strengthened in order to avoid erosion in this age old procedure in the era of technological explosion.

Chronic obstructive pulmonary disease (COPD) is a common preventable and treatable lifestyle-related disease with high global prevalence. COPD is associated with significant morbidity and mortality worldwide. Comorbidities are important events in the natural history of the disease and have a negative effect on the morbidity and mortality of COPD patients. Cardiac diseases, lung cancer, osteoporosis, and depression are common comorbidities reported for COPD. Recently, anemia has been recognized as a frequent comorbidity in COPD patients. The prevalence of anemia in patients with COPD varies from 7.5% to 33%. Anemia of chronic disease (ACD) is probably the most common type of anemia associated with COPD. ACD is driven by COPD-mediated systemic inflammation. Anemia in COPD is associated with greater healthcare resource utilization, impaired quality of life, decreased survival, and a greater likelihood of hospitalization. We need large prospective studies to discern the association between anemia and COPD.

Background and Objectives: Exercise-induced desaturation (EID) is associated with increased mortality in chronic obstructive pulmonary disease (COPD). However, the relationship of EID with anthropometric and clinical parameters of resting pulmonary function test and six-minute walk test (6MWT) in COPD remains unclear. The study was designed to assess the correlate of EID and to identify various possible predictors of EID in stable normoxemic patients of COPD. Materials and Methods: Sixty patients with stable COPD diagnosed and staged as per the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines underwent 6MWT. A drop in standard pulse oximetry (SpO 2 ) of ≥4% or nadir up to ≤88% was defined as EID. Based on EID during 6MWT, two groups were formed: desaturators (DS) and nondesaturators (NDS). DS and NDS were compared for baseline and clinical characters by the Student′s t-test while Pearson and Spearman rho correlation coefficient assessed strength of the association of anthropometric and clinical variables with EID. The predictors of EID were identified by logistic regression and receiver operator curve analysis. Result: Out of 60 patients with stable COPD, 33 patients desaturated on exercise (n = 33/60). DS had significantly lower values of FEV 1 (P < 0.001), FVC (P < 0.01) FEV 1 /FVC (P < 0.01) compared to NDS. EID had significant negative correlation with FEV 1 (r = 0.31, P < 0.01), resting oxygen saturation (r = 0.549, P < 0.001) and 6MWD (r = 0.511, P < 0.001). Resting SpO 2 ≤93% was found to a predictor of EID with a sensitivity and specificity of 83% and 78%, respectively. Interpretation and Conclusion: The 6MWT is a safe and sensitive test to recognize EID in normoxic stable COPD patients. Resting oxygen saturation is a good predictor of EID.

Introduction: Chronic obstructive pulmonary disease (COPD) is an important non-communicable disease worldwide with a rising global incidence. COPD is associated with multiple co-morbidities. Patients with COPD are at increased risk of atherosclerosis and other cardiovascular events. Cardiovascular diseases are an important cause of morbidity and mortality in COPD. The present case-control study was designed to assess the relationship between sub-clinical atherosclerotic vascular diseases with COPD. Methods: It was a prospective case-control blinded observational study. There were 142 COPD patients and 124 age-and sex-matched controls without COPD and cardiovascular diseases. Frequency of sub-clinical atherosclerosis was assessed by the carotid B-mode duplex ultrasonography assessment of carotid wall intima medial thickness (IMT). Plaque was defined as IMT of more than 1.2 mm. Results: Prevalence of carotid plaqing was significantly higher amongst patients of COPD (38.7%) compared to controls (13.7% , odds ratio 3.9, P < 0.0001). Multinomial logistic regression analysis revealed COPD as an independent predictor of carotid plaqing (r = 0.85, P < 0.023). Conclusion: The frequency of carotid plaqing is high in COPD patients. Carotid plaqing may be due to shared risk factors or the presence of low-grade systemic inflammation. Presence of increased CIMT and carotid plaqing in COPD patients identifies early atherosclerotic changes and future cardiovascular risk. Hence screening of CIMT should be a part of cardiovascular assessment in patients with COPD.

Peripheral T cell lymphomas are a heterogeneous group of post-thymic, mature lymphoid malignancies, accounting for approximately 10-15% of all non-Hodgkin's lymphomas. Hepatosplenic T-cell lymphoma (HSGDTCL) is a rare entity, which is characterized by primary extra nodal disease with typical sinusoidal or sinusal infiltration of the liver and the spleen, respectively by expression of the T cell receptor chain, and by a number of other frequent clinicopathologic features, including aggressive course of disease. Secondary involvement of liver by hematopoietic malignancies is much more common as compared to primary liver involvement. Primary involvement of liver by non- Hodgkin’s lymphoma (NHL) is documented and mostly DLBCL (diffuse large B cell lymphoma) type. But, T cell lymphoma primarily arising from liver is very rare. It occurred commonly in immunocompromised patients and prognosis is very poor. Here, we present two case reports of Hepatosplenic gamma-delta T-cell lymphoma (HSGDTCL) and both are immunocompetent patients. Liver biopsy from the mass and subsequent IHC (immunohistochemistry) were performed for the purpose of diagnosis, which were positive for LCA (leukocyte common antigen), CD2 and negative for CD5, CD20 and CD79a. First patient was a 63-year-old female with hepatitis C virus seropositivity presented with liver mass simulating hepatocellular carcinoma. Second patient was a 60-year- old male, chronic alcoholic patient, presented with liver mass and lytic bony lesion in pelvis. Both patients were managed with conventional CHOP (cyclophosphamide, hydroxydaunorubicin, vincristine, and prednisolone) and showed complete response after 4 cycles of chemotherapy. After completion of 6 cycles of chemotherapy, both patients remained under 6-month surveillance period for any recurrence of the disease.

Background: Effective and reliable venous access is one of the cornerstones of modern medical therapy in oncology. Materials and methods: This is a prospective observational study, which collected data of patients who require “PORT” catheter insertion for any cancer, at a tertiary care oncology hospital in Ahmadabad, Gujarat, India, during a 2-year period. Aims and objectives: The main objective of this study was to study the various complications and outcomes related to “PORT” catheters. Results: “PORT” catheter was inserted in 100 patients and was most commonly used in solid malignancies (n = 86, 86%), followed by hematologic malignancies (n = 14, 14%). Among the solid malignancies, breast cancer (38, 38%) was the most common underlying disease, whereas among the hematologic malignancies, acute lymphoblastic leukemia (6, 6%) was the most common underlying disease for “PORT” catheter insertion. Chemotherapy was started on the first day of “PORT” catheter in 74% of patients in the “PORT” study group. The various complications developed in the “PORT” study group in the descending order are as follows: 4 patients (4%) developed early infection (⩽30 days after “PORT” placement), 4 (4%) late infection (⩾30 days after “PORT” placement), 4 (4%) bloodstream infection, 2 (2%) local skin infection at the “PORT” insertion site, 2 (2%) dislodgment of the “PORT” catheter, 2 (2%) fracture of the “PORT” catheter, and 1 recurrent pleural effusion. One patient (1%) developed thrombosis as the complication of “PORT” catheter insertion. Conclusions: The most disturbing aspect of treatment for a patient with cancer is multiple painful venipunctures made for administration of cytotoxic agents, antibiotics, blood products, and nutritional supplements. The focus of this prospective observational research is to study the various underlying diseases for which “PORT” catheter is needed in different solid and hematologic malignancies and the various complications and outcomes in pediatric and adult patients with cancer.

Objective: To evaluate the utility of fiberoptic bronchoscopy in sputum smear negative PTB patients. Material and Methods: A total of 66 adult patients with sputum smear negative for Acid Fast Bacilli (AFB) and chest X-ray suggestive of pulmonary tuberculosis underwent fiberopticbronchoscopy (FOB). A thorough examination of bronchial tree was carried out and bronchoalveolarlavage (BAL) was taken and was sent for Ziehl-Neelsen staining, MGIT960 TBculture, pyogenicand fungal culture. Bronchial brushing, endo-bronchial and transbronchial lung biopsy(TBLB) wherever indicated were performed and Ziehl-Neelsen staining was performed and post bronchoscopy sputum(PBS) was also sent for Ziehl-Neelsen stain.Results are summarized in tables and percentages. Quantitative data is summarized using means& standard deviation. Cross tabulation with outcome variable of interest was done using statistical software Epi-info version 7 (7.1.1.0). A p-value of less than 0.05 was considered statistically significant. Results: Males constituted majority of our study population. The most common age group involved in the study was 18-28 years (36.3%). cough was the most common symptom reported by 62 patients (93.93%). The past history of PTB was present 6 patients (9.09%).Majority of study population, 39 patients (59.09%) had unilateral lesion on CXR. Out of 66 clinically suspected SSN-PTB patients, 52 patients (78.7%) were finally diagnosed as having active PTB. The diagnosis other than PTB was established in 6 (9.09%) cases, which included 3 cases of fungal (Candida) pneumonia and 3 cases of bacterial (pseudomonas species, citrobacter species, serratiamarsecens) pneumonia. Conclusions: FOB and various bronchoscopy guided procedures can provide a rapid and definitive diagnosis of PTB in sputum negative patients.

Introduction: COPD is a common preventable and treatable disease and a major cause of morbidity and mortality globally. ECG is a very simple, widely available and convenient bedside investigation that can be used to detect various cardiac abnormalities. Electrical activities of the heart are often influenced by COPD. ECG changes like P-wave abnormalities have to be carefully assessed before coming to an inference. Methodology: The present study was an institutional based prospective study, conducted from July 2014 to June 2015. The study was designed to assess the various ECG abnormalities in stable COPD patients and to determine echocardiography findings in relation to ECG changes. Results: Among the P-wave abnormalities P-wave axis verticalisation (PWAV) was observed in 59(76.6%) patients. Twenty (26%) patients showed negative P-wave in V1, significant-Ptf(P-terminal force) was observed in 3(3.9%) patients. P-mitrale was seen in 18(31.2%), and P-pulmonale in 16 (20.8%) patients. Conclusion: Though not specific, ECG may reveal various functional and structural abnormalities of the heart in relation to COPD like PWAV. PWAV may be the most commonly seen P-wave abnormalities in COPD patients. Echocardiography findings suggest that presence of P-mitrale is not conclusive of left atrial overload in patients of COPD. Echocardiography should be done routinely in all COPD patients to confirm ECG findings and to diagnose pulmonary hypertension, cor-pulmonale and other subclinical cardiovascular co-morbidities like left ventricular diastolic dysfunction.

Background and Objectives: Effect of tadalafil on cardiopulmonary haemodynamics in patients of chronic pulmonary diseases residing at an altitude has not been studied adequately. The present study reports the effect of tadalafil on cardiopulmonary haemodynamics in patients of chronic pulmonary diseases with PH residing at an altitude ranging between 1000 meters to 2500 meters above mean sea level. Methods: Seventy six patients of chronic pulmonary diseases with PH diagnosed by echocardiography were randomized to receive tadalafil 40 mg once a day or to the control group. The effect of tadalafil on cardiopulmonary haemodynamics was assessed after 3 months of tadalafil exposure. The echo Doppler derived indices of cardiopulmonary haemodymics recorded were; TR gradient, pulmonary flow acceleration time, pulmonary vascular resistance, myocardial performance index, RV eccentricity index, tricuspid annular plane systolic excursion and cardiac output. The arterial oxygen saturation was measured by Pulse oxymeter. Results and Interpretation: Tadalafil significantly improved the indices of RV performance; pulmonary flow velocity time integral (14.54 ± 3.17cm versus 12.25 ± 2.25cm, p

Digital clubbing is an ancient and important clinical signs in medicine. Although clubbed fingers are mostly asymptomatic, it often predicts the presence of some dreaded underlying diseases. Its exact pathogenesis is not known, but platelet-derived growth factor and vascular endothelial growth factor are recently incriminated in its causation. The association of digital clubbing with various disease processes and its clinical implications are discussed in this review.

Background: HIV/AIDS pandemic is responsible for the resurgence of TB worldwide, resulting in increased morbidity and mortality. HIV and Mycobacterium tuberculosis have a synergistic interaction; each propagates progression of the other. Coinfection with HIV infection leads to difficulties in both the diagnosis and treatment of tuberculosis, increase risk of death, treatment failure and relapse. Objective: The aim of the present study is to study the clinical, radiological profile of pulmonary and extrapulmonary tuberculosis (EPTB) in HIV-seropositive patients and their relationship to CD4 counts. Materials and Methods: It was a prospective study conducted over a period of 1 year in the department of medicine, Indira Gandhi Medical College, Shimla. We examined 87 HIV-infected patients with associated tuberculosis recruited from the department of medicine and antiretroviral center and were subjected to thorough clinical examination, X-ray chest, tuberculin testing and sputum examination for AFB and necessary relevant investigations for EPTB. Results: Most common affected age group was 31-40 years. EPTB is the commonest form of TB in our study detected in 65 patients. Commonest EPTB was CNS tuberculosis. Disseminated tuberculosis was only found in patient with CD4 count less than 200/cmm. Majority of lymph node TB was diagnosed by fine needle aspiration cytology (FNAC) examination. All patients with AFB-positive lymph node had CD4 count below 200/cum. Conclusions: The results of this study provide information regarding the various forms of TB and their presentation in HIV-infected persons. Early diagnosis of tuberculosis and prompt institution of antitubercular treatment (ATT) reduces mortality and morbidity significantly. In resource-poor areas, the diagnosis can be established with cytological/biochemical analysis of fluid, histopathological examination and ZN staining of tissue coupled with radiological features and response to ATT. Therefore, adequate knowledge of the manifestations of tuberculosis in HIV-infected patients is absolutely necessary for optimal management and to reduce mortality and morbidity.

Objective: the goal of this study was to assess the effectiveness and safety of bronchial (BAE) and/or non-bronchial (NBAE) systemic artery embolization in the management of hemoptysis, and the recurrence of hemoptysis within 3 months after embolization therapy. Material & Methods: A total of thirty patients who presented with various degrees of hemoptysis (massive, severe, moderate and mild) underwent bronchial artery embolization (BAE) / nonbronchial (NBAE) systemic artery embolization from July 2013 to June 2014. The effectiveness, safety, and the materials used in the embolization procedures were recorded along with short-term relapse. Results: Most of the patients had severe hemoptysis, reported in 16 (53.3%) cases, nine patients had massive (30%) and 5 (16.7%) patients had moderate hemoptysis. Hemoptysis was caused by tubercular sequelae (except aspergilloma) in 19 patients, active tuberculosis in 7patients, and aspergilloma and bronchogenic carcinoma in 2 patients each. A total of 70 arteries were embolized in 30 patients including 32 (46%) bronchial and 38 (54%) non-bronchial systemic arteries. The average number of arteries embolized per patient was 2.3. Complete resolution of hemoptysis was achieved within 24 hours in all 30 patients (100%). Rebleeding occurred within 30 days in seven patients. Only one patient had recurrent hemoptysis that occurred 30 days after the procedure. Chest pain was the most common post-embolization complication reported. Conclusion: Embolization therapy with appropriate technique is a safe and well-tolerated procedure with minor complications. It is important to embolize nonbronchial systemic arteries at the same setting, if they are angiographically shown to be contributing to hemoptysis.

Objective: To know the frequency and predictors of peripheral neuropathy and the abnormal visual evoked potentials in stable patients with chronic obstructive pulmonary disease. Material & Methods: All consecutive patients of stable COPD of age ≥ 40 years were screened for peripheral neuropathy. Total 57 patients of stable COPD of age ≥ 40 Years were selected. Spirometric examination was done in all the patients using an electronic portable based spirometer with printer. Neuro-physiological evaluation (neurological disability score-NDS), Mini Mental State Examination-questionnaire (MMSE), Visual analogue scale (VAS) were done on all subjects. The following nerves were evaluated for latency, amplitude, and conduction velocity. For motor nerve conduction: - median, ulnar, common peroneal and tibial nerves were evaluated. For sensory nerve conduction: - median, ulnar and sural nerves were evaluated. VEP was evaluated in all the 57 subjects. The continuous variables were described using means and analysis was done using independent t test. Results: Sub-clinical neuropathy was seen in 28 (49%) out of 57 stable COPD patients. Sensory neuropathy was seen in majority of patients. Sural nerve was the most commonly involved nerve. Neuropathy was predominantly axonal in nature. Abnormal VEP was found in 18 (32%) patients in whom P100 latency was more than 107. Conclusions: Electro-physiological testing showed the presence of peripheral neuropathy in 49% patients and abnormal VEP in 32% patients with stable COPD, who had no neurological symptoms. Maximum number of stable COPD patients with severe obstruction, heavy smoking index and bio-mass exposure had peripheral neuropathy, but statistically this was not found significant.

Background & Objectives: Anemia is a common co-existing entity in numerous chronic diseases like COPD, but has little published evidence stating its association with this disease. The effect of COPD on the health related quality of life and mortality in COPD patients, also remains least explored. The recent studies have suggested that anemia in patients with COPD has a frequent prevalence ranging from 7.5% to 34%. This data indicate towards the necessity of knowing the real prevalence and clinical impact of Anaemia of Chronic Disease in COPD and how does it affect their Health Related Quality of Life. Methods: This study was conducted on all consecutive stable COPD patients and related data was recorded. The St George Respiratory Questionnare (SGRQ) and the BODE index (Body Mass Index, FEV1, Dyspnoea, Exercise Capacity) was used to analyze the Health Related Quality of Life and the morbidity level of included patients. Results: 32 COPD patients had anaemia. The analysis showed significantly higher symptom score in the anaemic COPD patients (p=0.04). Also anaemics had significantly lesser BMI (p=0.03), significantly poor dyspnoea score (p=0.05) and significantly lesser six minute walk distance (p=0.05). Conclusions: The prevalence of anaemia in stable COPD patients is 32%, which is significantly associated with low BMI, dyspnoea and reduced exercise capacity. These factors can affect the quality of life of COPD patients thus, leading to increased morbidity. Hence, treating anaemia should hold a special place in treatment regime for COPD.

Background: Cognitive dysfunction is an important systemic effect of Chronic Obstructive Pulmonary Disease (COPD). The study aimed to investigate cognitive functioning in specific cognitive domains in COPD patients with different severity of disease. Materials & Method: Thirty one COPD patients with FEV1≥ 50%, twenty nine COPD patients with FEV1

For ancient period moon has been held responsible for many biological activities. That way, lunar cycle, by activity of moon, has been held responsible for increase in number of child birth. In this retrospective, observational study, we examined a total of 9890 full-term spontaneous deliveries as well as non-elective cesarean sections that occurred throughout 12 lunar months (February 7 th , 2008-January 25 th , 2009) in a rural medical college to evaluate the influence of the lunar position on the distribution of deliveries among Indian population. Student′s ′t′ test and ANOVA were used for statistical analysis where each delivery was considered as a single measure. We found no significant differences in the frequency of births during various phase of lunar cycle regardless of route of delivery. Our observations do not support the hypothesis of a relationship between lunar cycle and the frequency of obstetric deliveries.

Primary mediastinal sarcomas are aggressive tumors with a very rare incidence. This report describes the case of a 35-year-old male patient who presented with acute symptoms of dyspnoea, facial puffiness, voice-hoarseness, and engorged neck veins. With the clinical picture consistent with the superior vena cava (SVC) syndrome, the patient was investigated with computed tomography of the chest. This revealed a large soft tissue density mass lesion compressing the SVC along with other critical superior mediastinal structures. Histopathological evaluation of the mass revealed features consistent with a soft tissue sarcoma and positive staining was observed for vimentin and S-100. Cytogenetic analysis by fluorescent in situ hybridisation (FISH) demonstrated the t(X:18) translocation. Thus diagnosis was established as primary mediastinal synovial sarcoma. Patient was treated with three cycles of neoadjuvant chemotherapy, to which there was a partial response as per the RECIST criteria. Surgical excision of the mediastinal mass was performed, and further postoperative treatment with adjuvant chemoradiotherapy was provided. Patient currently is free of disease. This is to the best of our knowledge the first report in the world literature of a successfully treated case of “primary mediastinal sarcomas presenting as SVC syndrome.” Patient is under regular surveillance at our clinic and remains free of recurrence one year after treatment completion.

Myeloid sarcoma (chloroma, granulocytic sarcoma, or extramedullary myeloid tumour) is an extramedullary mass forming neoplasm composed of myeloid precursor cells. It is usually associated with myeloproliferative disorders but very rarely may precede the onset of leukemia. Here, we are presenting a rare case of primary vaginal myeloid sarcoma in a geriatric female patient without initial presentation of acute myeloid leukemia (AML). A 68-year-old female patient with ECOG Performance Score of 1 presented with pervaginal bleeding for 20 days. On colposcopic examination, she was found to have mass in the anterior fornix of vagina. A punch biopsy specimen revealed chloromatous infiltration of the vagina. LCA (leukocyte common antigen), MPO (myeloperoxidase), and c-kit were strongly positive on IHC (immunohistochemistry). The patient’s routine blood investigations were normal including peripheral smear, lactose dehydrogenase, uric acid, 2D echocardiography, conventional cytogenetics, bone marrow aspiration, and biopsy. The patient was given 4 cycles of decitabine (Decitex, manufactured by Sun Pharmaceutical Industries Limited, India), 20 mg/m2 for 5 days at an interval of 28 days. There was a partial response to decitabine according to RECIST criteria. As decitabine therapy was well tolerated, we are continuing in the same way until disease progression without any complications. The patient is undergoing regular follow-up at our centre.