Central venous catheterization (CVC) is routinely performed in emergency and critical care settings and is generally considered safe, particularly when ultrasound guidance is used. However, rare and potentially fatal delayed complications may still occur. Delayed perforation of the superior vena cava (SVC) is exceedingly uncommon and may be under-recognized, especially following right-sided catheterization. A 63-year-old woman underwent ultrasound-guided right subclavian central venous catheterization prior to emergency laparotomy for small bowel obstruction. The procedure was uneventful. Blood return was confirmed in all lumens, and post-procedure chest radiography demonstrated appropriate catheter tip position within the lower SVC. Thirty hours postoperatively, she developed acute respiratory distress and hemodynamic instability. Imaging revealed a massive right-sided pleural effusion. Intercostal drainage yielded approximately 2.5 L of clear, low-protein fluid with biochemical features consistent with hydrothorax. Pleural fluid pH measured using a blood gas analyzer was 6.2. No alternative etiology for the rapidly accumulating effusion was identified. The catheter was immediately removed for presumed catheter-related vascular perforation. Despite aggressive supportive care, the patient developed refractory shock with multiorgan dysfunction and died on postoperative day 12. This case highlights delayed SVC perforation as a rare but catastrophic complication of central venous catheterization, even when performed under ultrasound guidance using right-sided access. Clinicians must maintain a high index of suspicion for catheter-related vascular injury in patients who develop unexplained pleural effusion or circulatory compromise after recent central venous access.

Primary tracheal tumors are rare, particularly in adults, and most are malignant. Mucoepidermoid carcinoma (MEC) of the tracheobronchial tree is an exceptionally uncommon entity, with occurrence during pregnancy being even rarer. A review of the PubMed and Scopus databases reveals only seven reported cases of MEC diagnosed during pregnancy. We report the case of a 20-year-old pregnant woman at 23 weeks’ gestation who presented with a severe asthma exacerbation refractory to standard therapy. Further evaluation revealed a low-grade tracheal mucoepidermoid carcinoma causing near-complete airway obstruction. The patient was successfully managed with interventional bronchoscopy using electrocautery snaring and argon plasma coagulation (APC). This case highlights the importance of early imaging and bronchoscopy in patients with atypical or treatment-refractory asthma, including during pregnancy.

Primary tracheal tumors are rare occurrence, particularly in adults, with the majority of them being malignant. Among these malignant primary tracheal tumors, mucoepidermoid carcinoma of the tracheobronchial tree is exceptionally uncommon. Its occurrence during pregnancy is even rarer. A comprehensive review of medical literature in PubMed and Scopus databases has revealed only seven reported cases of mucoepidermoid carcinoma during pregnancy to date. We present the case of a 20-year-old pregnant woman at 22 weeks of gestation who was transferred to our facility due to a life-threatening exacerbation of bronchial asthma. Further evaluation at our institution led to the diagnosis of low-grade mucoepidermoid carcinoma, and her condition was managed using interventional bronchoscopic procedures, including electrocautery snaring and Argon-Plasma Coagulation (APC).

Pulmonary infiltrates with eosinophilia are a heterogeneous group of disorders that are characterized by pulmonary infiltrates on chest radiograph and elevated levels of eosinophils in the peripheral blood. Among patients with these disorders, reports of either allergic bronchopulmonary aspergillosis (ABPA) or tropical pulmonary eosinophilia (TPE) are common. However, the simultaneous occurrence of ABPA and TPE is not often reported. We present the case of a young man with a history of asthma who was diagnosed with ABPA and TPE. Initially, the patient exhibited a partial response to treatment of ABPA, but persistent symptoms and eosinophilia led to suspicion and subsequent diagnosis of TPE. With implementation of antifilarials and steroids, the patient experienced satisfactory clinical and serological improvements. This case underscores the importance of considering multiple diagnoses in patients with overlapping symptoms and highlights the need for comprehensive management strategies in complex lung diseases.

Battlefield injuries result in acute and severe uncontrolled pain, which can be reduced with the early use of analgesia. Apart from pain, battlefield injuries may also cause significant morbidity and a prolonged period of absence from active duty. Traditionally available opioids are known to cause various undesirable side effects such as respiratory depression that may worsen the condition of an already injured combatant. Nalbuphine is an opioid agonist-antagonist and has been increasingly used for postoperative analgesia over the last decade. In India, it is the only opioid analgesic that does not come under the Controlled Substances Act at the time of this publication. In today's world, where nalbuphine is being recommended for acute pain worldwide, its use in the Indian combat scenario needs to be conceptualized at the medical officer level (primary caregiver). This conceptualization will be discussed in detail in this review article.

Background:Anti-personnel mine injuries (APMI) confined to the lower limbs (type I) are common, however, their remote effects on the lungs are exceptional. The present study was done to analyze the pulmonary complications following type I mine blast injuries. Methods:APMI managed between Jan 2020 and Oct 2023 at a military facility in Jammu & Kashmir were audited, focusing upon the pulmonary complications. Results:Twenty-four males, aged 21-42 yrs, had sustained type I injuries due to accidentally stepping over the mines, during the study period. Six of them (25%) developed pulmonary complications of post-blast lung injury (PBLI) in a delayed timeline, hitherto unseen ie after 36-72 h of injury. Two patients (8%) developed concurrent pulmonary thromboembolism (PTE), unexpectedly early, necessitating therapeutic anticoagulation in the immediate postoperative period. Conclusions:PBLI and PTE may follow type I mine blast injuries in an unanticipated timeline. Continued suspicion for timely detection of blast lung and early thromboprophylaxis to prevent PTE is suggested.

Meigs syndrome (MS) is characterized by a benign ovarian tumor (fibroma), hydrothorax on the right side, and ascites; which can be resolved permanently after surgery. Available literature reveals that most MS surgeries were performed under general anesthesia (GA)[1]. However, GA poses major risks to the patient. Considering the high risk of gastric content regurgitation, poor general condition or dyselectrolytemia may lead to delayed arousal, and associated multi-organ dysfunction. Intraoperative mechanical ventilation is also difficult due to ascites and hydrothorax (reduced cardiac output, impaired ventilation-perfusion in lungs causing hypoxia and hypercapnia)[1,2]. In this letter, we report a case of MS tumor resection under the subarachnoid block (SAB) to mitigate these issues and also review the complications associated with both techniques.

Background:The fight against tuberculosis in our country has taken a new shape with the inclusion of rapid nucleic acid amplification tests like GeneXpert MTB/RIF assay which rapidly detects Mycobacterium tuberculosis and rifampicin resistance. Rifampicin resistance detected on GeneXpert has been considered as a sine qua non for the presence of isoniazid resistance and hence classified as multidrug-resistant tuberculosis (MDR-TB). However treatment of rifampicin-resistant, isoniazid-monoresistance, and MDR-TB are different. Our study was done with the aim of identification of the prevalence of isoniazid resistance on culture, in cases which had rifampicin resistance on GeneXpert.Methods:Pulmonary samples of patients of presumptive tuberculosis were subjected to GeneXpert testing and liquid MGIT (mycobacterium growth indicator tube) culture. On detection of rifampicin resistance on MTB/RIF assay, the patients were included in our study and cultures were followed-up for sensitivity to isoniazid. A total of 76 patients were included.Results:76 patients of rifampicin resistance on GeneXpert MTB/RIF assay were followed-up for the sensitivity of isoniazid on culture media. Out of the 76 cases, 62 (81.57%) were found to have isoniazid resistance. Out of the 14 patients, the cultures showed no growth in 6, and in the rest, isoniazid was found to be sensitive.Conclusion:GeneXpert MTB/RIF assay is an excellent modality for the detection of M. tuberculosis and rifampicin resistance. The decision to exclude isoniazid from the treatment regimen in patients with rifampicin resistance should be made only after conducting further molecular/phenotypic tests.

Autoimmunity has been extensively established as a characteristic feature of the post-COVID-19 syndrome. There is evolving evidence of immune system dysregulation leading to the development of autoimmune phenomena in patients with COVID-19. This immune dysregulation may range from the production of autoantibodies to the new onset of rheumatic autoimmune diseases. An extensive literature search in databases from December 2019 to date revealed that no cases of autoimmune pulmonary alveolar proteinosis (PAP) were reported in post-COVID patients. In this context, we report a novel case series of two cases of new-onset autoimmune PAP in post-COVID patients, an entity that has not been described before. We recommend further studies to better understand this association between new-onset autoimmune PAP and SARS-CoV-2.

Introduction: Gastrointestinal (GI) manifestations and liver function abnormalities have been reported in Coronavirus Disease-2019 (COVID-19). However, data is variable and lacking from the Indian Population. Moreover, the prognostic implication of these manifestations has not been well-defined. Aim: To determine the impact of COVID-19, on the gastrointestinal tract and Liver Function Test (LFT) and develop a prognostic model for mortality. Materials and Methods: An observational descriptive study was conducted in the Department of Internal Medicine at a temporary dedicated COVID-19 centre in a Tertiary Care Cardiothoracic Centre, Western Maharashtra, India. The hospital records of all the patients admitted from July 2020 to September 2020 were analysed. Clinical details and laboratory details were obtained from 589 Reverse Transcription– Polymerase Chain Reaction (RT-PCR) confirmed patients. The data was analysed and a prognostic scoring system was developed. Patients with positive Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) RT-PCR on nasopharyngeal or oropharyngeal swabs. The data was entered in Microsoft Excel 2010 worksheet and t-test or Mann-Whitney test was also applied to compare the mean of variables being studied by separation of living and deceased patients based on the normality of the quantitative data. Results: The mean age±SD of the study participants was 44.74±19.61 years. The majority {127/589 (21.56 %)} of the patients were in the age group of 51-60 years. A total of 5 (0.84%) out of 589 patients had diarrhoea, and 3 (0.51%) had vomiting at the time of admission. Elevated Aspartate Aminotransferase (AST), Alanine Transaminase (AST), Alkaline Phosphatase (ALP), Gamma-glutamyl Transferase (GGT), Lactate Dehydrogenase (LDH), Creatine Kinase Myocardial Band (CK-MB) was reported in non survivors in 45 (90%), 39 (78%), 15 (30%), 28 (56%), 48 (96%) and 49 (98%) out of 50 cases, respectively. The prognostic scoring system was developed with the following variables: age, Diabetes Mellitus (DM), symptomatic, breathlessness, albumin, AST, ALP, LDH, Prothrombin Time (PT), D-Dimer. The area under the curve, came out to be 0.91 and a cut-off value of three in the scoring system was able to predict death at a sensitivity of 85.5% and specificity of 79.6%. Conclusion: Gastrointestinal manifestations and abnormalities in LFTs are important extrapulmonary manifestations of COVID19. Patients with abnormal liver tests had higher risks of progressing to severe disease. Hence, LFT should be monitored and evaluated frequently during hospitalisation for COVID-19.

Examination of her abdomen revealed no tenderness, distension, or visceromegaly.Rest of the systemic examination was unremarkable.On evaluation, she had normochromic normocytic anemia with hemoglobin of 9.0 gm/dL.Total counts were in normal range but had thrombocytosis (5.21 lacs/cumm) and a high erythrocyte sedimentation rate of 122 mm fall in 1st hour.Liver and renal functions were within normal range, and plasma glucose was 113 mg/dL.Rest of the biochemical markers were in normal range.Chest radiograph (Fig. 2A) showed bilateral cavitary nodular lesions in middle and lower zones.Contrast-enhanced computed tomogram (CECT) of chest (Fig. 2B) showed multiple cavitary lesions bilaterally in the upper and middle lobes.High-resolution computed tomogram of the temporal region showed bilateral cholesteatoma with coalescent mastoiditis and chronic otitis media.Sputum analysis was, however, negative for acid-fast bacilli and other microorganisms.Immunological workup revealed antineutrophil antibodies negative by indirect immunofluorescence but cytoplasmic-antineutrophil cytoplasmic antibodies (c-ANCA) was positive (76.94 U/L), and perinuclear-anti-

BackgroundThe Solidarity trial among COVID-19 inpatients has previously reported interim mortality analyses for four repurposed antiviral drugs. Lopinavir, hydroxychloroquine, and interferon (IFN)-β1a were discontinued for futility but randomisation to remdesivir continued. Here, we report the final results of Solidarity and meta-analyses of mortality in all relevant trials to date.MethodsSolidarity enrolled consenting adults (aged ≥18 years) recently hospitalised with, in the view of their doctor, definite COVID-19 and no contraindication to any of the study drugs, regardless of any other patient characteristics. Participants were randomly allocated, in equal proportions between the locally available options, to receive whichever of the four study drugs (lopinavir, hydroxychloroquine, IFN-β1a, or remdesivir) were locally available at that time or no study drug (controls). All patients also received the local standard of care. No placebos were given. The protocol-specified primary endpoint was in-hospital mortality, subdivided by disease severity. Secondary endpoints were progression to ventilation if not already ventilated, and time-to-discharge from hospital. Final log-rank and Kaplan-Meier analyses are presented for remdesivir, and are appended for all four study drugs. Meta-analyses give weighted averages of the mortality findings in this and all other randomised trials of these drugs among hospital inpatients. Solidarity is registered with ISRCTN, ISRCTN83971151, and ClinicalTrials.gov, NCT04315948.FindingsBetween March 22, 2020, and Jan 29, 2021, 14 304 potentially eligible patients were recruited from 454 hospitals in 35 countries in all six WHO regions. After the exclusion of 83 (0·6%) patients with a refuted COVID-19 diagnosis or encrypted consent not entered into the database, Solidarity enrolled 14 221 patients, including 8275 randomly allocated (1:1) either to remdesivir (ten daily infusions, unless discharged earlier) or to its control (allocated no study drug although remdesivir was locally available). Compliance was high in both groups. Overall, 602 (14·5%) of 4146 patients assigned to remdesivir died versus 643 (15·6%) of 4129 assigned to control (mortality rate ratio [RR] 0·91 [95% CI 0·82–1·02], p=0·12). Of those already ventilated, 151 (42·1%) of 359 assigned to remdesivir died versus 134 (38·6%) of 347 assigned to control (RR 1·13 [0·89–1·42], p=0·32). Of those not ventilated but on oxygen, 14·6% assigned to remdesivir died versus 16·3% assigned to control (RR 0·87 [0·76–0·99], p=0·03). Of 1730 not on oxygen initially, 2·9% assigned to remdesivir died versus 3·8% assigned to control (RR 0·76 [0·46–1·28], p=0·30). Combining all those not ventilated initially, 11·9% assigned to remdesivir died versus 13·5% assigned to control (RR 0·86 [0·76–0·98], p=0·02) and 14·1% versus 15·7% progressed to ventilation (RR 0·88 [0·77–1·00], p=0·04). The non-prespecified composite outcome of death or progression to ventilation occurred in 19·6% assigned to remdesivir versus 22·5% assigned to control (RR 0·84 [0·75–0·93], p=0·001). Allocation to daily remdesivir infusions (vs open-label control) delayed discharge by about 1 day during the 10-day treatment period. A meta-analysis of mortality in all randomised trials of remdesivir versus no remdesivir yielded similar findings.InterpretationRemdesivir has no significant effect on patients with COVID-19 who are already being ventilated. Among other hospitalised patients, it has a small effect against death or progression to ventilation (or both).FundingWHO.

Pneumomediastinum and pulmonary embolism are known complications of the COVID-19 disease. Our patient developed spontaneous pneumomediastinum twice during hospital admission along with acute pulmonary embolism. We managed this patient conservatively sticking to the basics of critical care and had a successful outcome. In our extensive literature search, we could not find any other case in which a patient with COVID-19 not on mechanical ventilation developed spontaneous pneumomediastinum twice during the hospital admission which was successfully managed conservatively.

Cotton dust exposure has been implicated in causing diseases like byssinosis and obstructive airway diseases like COPD and asthma. Long-term exposure to cotton dust causing interstitial lung disease and pulmonary fibrosis has been sparsely reported in the literature. Here, we report a case of an individual with long-term cotton dust exposure who presented with typical symptoms of interstitial lung disease and was managed conservatively.

BACKGROUND:Pulmonary embolism (PE) has been identified as one of the deadliest complications of coronavirus disease 2019 (COVID-19), especially in patients admitted to the intensive care unit (ICU). Western literature reminds us of the high prevalence of PE in COVID. Here, we report a series of 13 cases of PE diagnosed and managed at our hospital.METHODS:Retrospective analysis of medical records of 13 cases of PE admitted at our hospital from February 1, 2020, to September 31, 2020, were done. Their clinical, laboratory, and radiologic data were assessed in detail.RESULTS:Computed tomography pulmonary arteriography was used to make the diagnosis in eight patients (61.53%), and clinical findings with corroborative ultrasound and laboratory parameters were used to label PE in five patients (38.46%). Five patients were hemodynamically unstable, requiring thrombolysis with recombinant tissue plasminogen activator, and four patients (30.76%) suffered a fatal outcome.CONCLUSION:COVID-19 is a highly prothrombotic state, and all physicians should keep a high vigilance for PE. All hospitalized patients with COVID-19, especially those admitted in ICU, should be on prophylactic anticoagulation and, if there is any worsening, should be started on therapeutic regimen. Patients at the time of discharge should be switched to oral anticoagulation, which should be continued for at least 3-6 months.

Background A mass lesion in the lung is a common finding seen on chest radiology. The prognosis of patients with mass lesions in the lung is capricious as malignancy is a consideration. It is essential to diagnose the underlying aetiology at the earliest with minimally invasive procedures for prompt treatment of the case. Bronchoscopic lung cryobiopsy (BLC) is a newer interventional technique in pulmonary medicine for the diagnosis of mass lesions in the lung. Materials and methods This is a retrospective study of patients reporting to a tertiary care centre who were radiologically (by computed tomography scan of the chest) diagnosed with a mass lesion of the lung and who underwent BLC during the period from January 2018 to January 2021. We analysed the diagnostic yield of the technique defined as a positive tissue diagnosis after the histopathological examination (HPE) along with the safety of the procedure. Results During the above period, we evaluated 70 patients who were diagnosed radiologically with mass lesions of the lung and underwent BLC. We obtained tissue diagnoses for 66 cases and the result of four cases was inconclusive. The diagnostic yield of the BLC procedure was 94.29%. There was no mortality and complications were minimal bleeding and small pneumothorax. Conclusion BLC is a newer technique for obtaining lung tissue via a flexible bronchoscope obviating the need for open lung biopsy. The main advantage of the technique is providing larger tissue samples with minimal or no side effects without undergoing multiple procedures as compared to other bronchoscopic or surgical methods for obtaining a diagnosis from lung tissue. BLC is a safer and promising technique in diagnosing mass lesions of the lung with better yield.

Background:Acute Pulmonary thromboembolism (PTE) is associated with acute hypoxemic respiratory failure (AHRF), which is a leading cause of death in these patients. High-Flow Nasal Cannula (HFNC) oxygen therapy is a cornerstone of the treatment of respiratory failure. The aim of the present study is to explore the efficacy of HFNC in the treatment of patients of acute PTE with acute hypoxemic respiratory failure in India. Methods:This is a retrospective study of patients admitted to a tertiary care center with acute PTE with AHRF during the period from January 2018 to January 2020. After reviewing medical files, patients of acute PTE with AHRF treated with HFNC were included in the study. We analyzed the improvement in oxygenation parameters and respiratory rate, as well as outcome in these patients. Results:During the above specified period, 12 patients suffering from PTE with AHRF were treated with HFNC. After 1 h of the initiation of HFNC along with anticoagulation, the respiratory parameters of patients significantly improved. HFNC was applied for a period of 6-10 days. None of the patients required intubation for AHRF, and all patients were discharged from the hospital on oral anticoagulants. Conclusion:HFNC oxygen therapy in patients with acute PTE with AHRF showed rapid improvement of oxygenation and respiratory rate. HFNC oxygen therapy is an efficacious treatment for patients with AHRF secondary to acute PTE without any significant hemodynamic effect. It acts as a superior modality of oxygen therapy avoiding noninvasive and invasive ventilatory support.