Case Report: Pulmonary sarcomatoid carcinoma in a female patient from Nepal

Sarcomatoid carcinoma of the lung is an uncommon subtype of non-small-cell lung cancer (NSCLC). Even in the early stages, pulmonary sarcomatoid carcinoma (PSC) has a dismal prognosis when compared to other kinds of NSCLC with a mean survival of 9–12 months and a five-year survival rate of around 20%. We present the case of a 68-year-old woman with a two-month history of shortness of breath and cough. Initial computed tomography (CT) scan showed features of interstitial lung disease with chronic obstructive airway changes. After 34 months, the patient’s condition worsened with newer complaints of sore throat and hemoptysis. A repeat CT scan showed a ∼49x38x59mm size lesion in the superior segment of the left lower lobe. A core needle biopsy was performed, which revealed tumor cells consisting of irregular tubules and sarcomatoid components. The patient was started on chemotherapy. Unfortunately, she succumbed to her disease. Our case highlights the aggressiveness of PSC.

Unusual case of chronic cavitary pulmonary aspergillosis presenting as spontaneous pneumothorax in an immunocompromised man

Chronic cavitary pulmonary aspergillosis (CCPA) is a slow destructive type of chronic pulmonary aspergillosis, characterised by multiple pulmonary cavities that develop and expand over several months or years. Pleural involvement in the form of pneumothorax has been rarely reported in CCPA. We report such an unusual case of an immunocompromised male, with a history of chronic cough and fever, presenting with acute onset of shortness of breath. Chest imaging showed bilateral multiple cavitating nodules, ground glass opacities and dense right middle lobe consolidations and right-sided pneumothorax. Bronchoalveolar lavage (BAL) showed septate hyaline hyphae on KOH (potassium hydroxide) staining and fungal culture grew Aspergillus fumigatus. BAL and serum galactomanan were positive and serum IgG for A. fumigatus was 58 MgA/L (0–40MgA/L) confirming the cause of spontaneous secondary pneumothorax in our patient as CCPA.

Mobilization of Patients Receiving Extracorporeal Membrane Oxygenation Before Lung Transplant

Background Extracorporeal membrane oxygenation is increasingly used to provide cardiopulmonary support to patients awaiting lung transplant. Although studies have shown that these patients benefit from early mobilization, the care team often has concerns about related complications, particularly for patients requiring femoral cannulation. Objective To assess the safety of mobilizing patients receiving extracorporeal membrane oxygenation before lung transplant using a standardized mobility protocol. Methods A retrospective review was performed of the electronic health records of patients receiving extracorporeal membrane oxygenation before or immediately after lung transplant who were mobilized according to a standardized protocol from April through October 2018. The setting was an 18-bed cardiothoracic intensive care unit in a Magnet-designated teaching hospital. Patients were helped to ambulate by an interdisciplinary team, with careful assessment for any related complications. Results During the study period, 37 patients received extracorporeal membrane oxygenation, and 9 were mobilized. Two hundred forty-two therapy sessions were conducted involving 47 700 feet of ambulation. Patients experienced the following complications: chugging (1 patient), decrease in flow rate (2 patients), bleeding at the cannula site (2 patients), neck hyperextension (1 patient), fear/anxiety (1 patient), and shortness of breath (2 patients). Bleeding and neck hyperextension led to discontinuation of therapy until the problems were resolved. No changes were made to the protocol. Conclusions Patients receiving extracorporeal membrane oxygenation before lung transplant, including those with femoral cannulation, can be mobilized safely with the use of an interprofessional ambulation protocol. Further evaluation is indicated, including research on clinical outcomes.

Acid-Base Disorder in the Patients Visiting the Emergency Department of a Tertiary Care Hospital: A Descriptive Cross-sectional Study

Introduction: An acid-base disorder is a change in the normal value of extracellular pH that may result when renal or respiratory function is abnormal or when an acid or base load overwhelms their excretory capacity. Clinical acid-base disorders are conventionally defined from the vantage point of their impact on carbonic-acid-bicarbonate buffer system. The aim of the study is to find out the prevalence of acid-base disorder among patients visiting the emergency department of a tertiary care hospital. Methods: This is a descriptive cross-sectional study conducted among 370 patients who underwent arterial gas analysis at the emergency department of a tertiary care hospital. The study was carried out from 15th July 2016 to 15th July 2017 after receiving ethical approval from Institutional Review Committee. Convenient sampling was done. Point estimate at 95% Confidence Interval was calculated along with frequency and proportion for binary data. Data were entered in Microsoft-Excel. Statistical Package for Social Sciences version 17 was used for analysis. Results: Out of 370 patients analyzed, 329 (88.91%) (84.68-91.311 at 95% Confidence Interval) had acid-base disorder. The mixed disorder was the most common finding 80 (21.6%), followed by compensated Respiratory Acidosis 56 (17.8%). The mean age group of male patients studied was 50.72±20.586 and among females, it was 49.95±20.908 Among those most common symptoms were shortness of breath 151 (40.81%) followed by vomiting 91 (24.59%). Conclusions: Most common acid-base disorder was mixed disorder presenting with prominent symptoms of shortness of breathe in non-geriatric patients wherein the geriatric patient, the most common disorder was compensated respiratory acidosis with the prominent symptom of shortness of breath.

Development of a Post-Acute Sequelae of COVID-19 (PASC) Symptom Lexicon Using Electronic Health Record Clinical Notes

Objective: To develop a comprehensive post-acute sequelae of COVID-19 (PASC) symptom lexicon from clinical notes to support PASC symptom identification and research. Methods: We identified 26,117 COVID-19 positive patients from the Mass General Brigham's electronic health records (EHR) and extracted 328,879 clinical notes from their post-acute infection period (day 51-110 from first positive COVID-19 test). The PASC symptom lexicon incorporated Unified Medical Language System (UMLS) Metathesaurus concepts and synonyms based on selected semantic types. The MTERMS natural language processing (NLP) tool was used to automatically extract symptoms from a development dataset. The lexicon was iteratively revised with manual chart review, keyword search, concept consolidation, and evaluation of NLP output. We assessed the comprehensiveness of the lexicon and the NLP performance using a validation dataset and reported the symptom prevalence across the entire corpus. Results: The PASC symptom lexicon included 355 symptoms consolidated from 1,520 UMLS concepts. NLP achieved an averaged precision of 0.94 and an estimated recall of 0.84. Symptoms with the highest frequency included pain (43.1%), anxiety (25.8%), depression (24.0%), fatigue (23.4%), joint pain (21.0%), shortness of breath (20.8%), headache (20.0%), nausea and/or vomiting (19.9%), myalgia (19.0%), and gastroesophageal reflux (18.6%). Discussion and Conclusion: PASC symptoms are diverse. A comprehensive PASC symptom lexicon can be derived using a data-driven, ontology-driven and NLP-assisted approach. By using unstructured data, this approach may improve identification and analysis of patient symptoms in the EHR, and inform prospective study design, preventative care strategies, and therapeutic interventions for patient care.

Prevention of the development of adverse reactions in the treatment of tuberculosis in combination with diabetes mellitus

Background. In recent decades, tuberculosis (TB) and its resistant forms have become an increasing problem in lowincome countries, especially in countries with epidemics of HIV infection and insulin-dependent diabetes mellitus (DM). DМ has been shown to adversely affect TB treatment outcomes. Low treatment outcomes for TB/DM comorbidity are associated with age, weight gain, or poor glycemic control, and it is the increased duration of DM treatment that may be the best strategy for improving outcomes in TB/DM patients. In the formation of the development of polyneuropathy, one of the components is increasing ischemia and intracellular hypoxia, which is characteristic of TB/DM. Decreased blood flow contributes to the destabilization of cell membranes and neuronal death. The interconnected components of the immune and other systems, namely pro-inflammatory cytokines, play an important role in the formation and progression of these processes. Results and discussion. Our clinical assessment of the general condition of patients with TB/DM (23 patients) showed that 91.5 % of the examined patients complained of persistent cough with sputum production, 78 % had shortness of breath, weight loss of more than 5 kg – 89.8 %, thirst – 80 %, 75 % – tingling and numbness of the lower extremities, pain in the legs at night – 85.5 % of people. Sub-febrile temperature (37.4-37.9 °C) was registered in 52.2 % of the examined patients. The general condition of moderate severity prevailed in 49.5 % of patients. Intoxication syndrome (IS) in TB/DM patients by clinical and paraclinical signs was observed in all patients, respectively, pronounced (manifest) IS was recorded in 79.5 %. Body mass index is on average 15.6 kg/m2 (p<0.001). To prevent the development of polyneuropathy, patients with TB/DM was prescribed anti-TB drugs, insulin and additionally pathogenetic therapy according to the scheme: Neuromax, 2 ml intravenously, intramuscular once a day for 7 days, followed by the administration of the drug 2 times a week for 3 weeks, and with the subsequent transition to the tablet form – 1 tablet per day (until the end of the intensive phase of treatment), then Dialipon 3 % solution of 20 ml was prescribed intravenously drip for 7 days (the contents of the ampoule are diluted in 250 ml of 0.9 % sodium chloride solution), with the subsequent transition to a tablet form of 300 mg – 2 tablets once a day for a month. Conclusions. The proposed method makes it possible to effectively prevent adverse reactions in the treatment of TB in combination with DM, reduce the manifestations of peripheral polyneuropathy, provide better tolerance to anti-TB drugs, normalize clinical blood parameters, accelerate the rate of normalization of the content of some pro (IL-6, IL-18) and anti-inflammatory (IL-10) cytokines in the blood plasma of patients, which, in turn, reduces the percentage of refusals from the treatment of comorbid pathology.

Diagnostic Challenges of Pneumocystis Pneumonia during the COVID-19 Pandemic: A Case of a Young Patient with Ground Glass Opacities and Pulmonary Embolism on Chest CT

The coronavirus disease 2019 (COVID-19) pandemic is wreaking havoc across the globe. This pandemic has given rise to a mindset where physicians tend to neglect other causes of pneumonia, especially if the patient presents with signs and symptoms commonly associated with COVID-19. Herein, we report a case of a young man presenting to the emergency department with common clinical, radiological, and laboratory features of COVID-19 pneumonia such as shortness of breath, hypoxia, pulmonary embolism, elevated D-dimer, and bilateral ground glass opacities on computed tomography of the chest but was later diagnosed with Pneumocystis pneumonia that was treated with appropriate antibiotics and corticosteroids. This case highlights the importance of performing a thorough clinical history and differentiating the clinical and radiological features of COVID-19 pneumonia from pneumonia of other etiologies.

The Effect of Low-Intensity Hairmyres Exercises on Six-Minute Walk Distance in Patients with Chronic Obstructive Pulmonary Disease: A Preliminary Study ABSTRACT

ABSTRACTIntroduction: Therapeutic exercise is the main rehabilitation program in patients with Chronic Obstructive Pulmonary Disease (COPD). Shortness of breath due to persistent obstruction causes disability in the form of decreased functional capacity. Hairmyers is an isolated group of exercise to recondition the limb muscles without weights. The purpose of this study was to assess the efficacy of low-intensity Hairmyres exercise in improving Six-Minute Walk Distance (6MWD).Methods: This is a pre-post interventional study held from January to April 2005. Hairmyres exercises were given to the patients (n=14) with moderate and severe COPD for eight weeks, five times a week with two exercises performed in front of the researcher. Six-Minute Walk Distance was measured before, at the end of the 4 th week, and after the exercise program.Results: Compared to the beginning, the 6MWD increased by 27 meters at the end of the 4th week and 62.29 meters at the end of the program in moderate COPD patients, while the increase in severe COPDpatients were 39.71 and 76 meters, respectively. There was a significant difference (p <0.05) between the first and the last measurement in both groups. This difference also surpassed the minimal clinicallyimportant difference (MCID) of 6MWD.Keywords: COPD, Hairmyers, Low-Intensity Exercise, 6MWD

Chronic lymphocytic leukemia; an incidental finding in a COVID-19 patient.

We report a case of 57 years old male, with no prior comorbids functional class I, presented with a history of fever for one week along with shortness of breath and cough for 5 days. Upon workup his baseline CBC reported bicytopenia along with marked lymphocytosis which raised the suspicion and to confirm the diagnosis, his acute leukemia comprehensive panel was done which reported an incidental finding of Chronic lymphocytic leukemia along with concomitant COVID PCR positive. This patient also presented with Tumor Lysis Syndrome and Acute kidney Injury.

Incidence of Acute Myocardial Infarction in Northern Tanzania: A Modeling Approach Within a Prospective Observational Study

Background Rigorous incidence data for acute myocardial infarction (AMI) in sub‐Saharan Africa are lacking. Consequently, modeling studies based on limited data have suggested that the burden of AMI and AMI‐associated mortality in sub‐Saharan Africa is lower than in other world regions. Methods and Results We estimated the incidence of AMI in northern Tanzania in 2019 by integrating data from a prospective surveillance study (681 participants) and a community survey of healthcare‐seeking behavior (718 participants). In the surveillance study, adults presenting to an emergency department with chest pain or shortness of breath were screened for AMI with ECG and troponin testing. AMI was defined by the Fourth Universal Definition of AMI criteria. Mortality was assessed 30 days following enrollment via in‐person or telephone interviews. In the cluster‐based community survey, adults in northern Tanzania were asked where they would present for chest pain or shortness of breath. Multipliers were applied to account for AMI cases that would have been missed by our surveillance methods. The estimated annual incidence of AMI was 172 (207 among men and 139 among women) cases per 100 000 people. The age‐standardized annual incidence was 211 (263 among men and 170 among women) per 100 000 people. The estimated annual incidence of AMI‐associated mortality was 87 deaths per 100 000 people, and the age‐standardized annual incidence was 102 deaths per 100 000 people. Conclusions The incidence of AMI and AMI‐associated mortality in northern Tanzania is much higher than previously estimated and similar to that observed in high‐income countries.