ACM Inroads

Abstract Measles is a highly contagious viral illness that can lead to severe complications, especially in unvaccinated individuals. While the acute phase of the disease is well-characterized, the potential for delayed and life-threatening complications, even during the convalescent phase, is less widely recognized. Here, we present the case of a previously healthy 18-year-old female who developed tention pneumothorax and extensive lung injury approximately 6 weeks after the onset of a measles infection. The patient was initially presented with dyspnea, chest pain, and respiratory distress. Diagnostic imaging confirmed the presence of tension pneumothorax and diffuse lung parenchymal injury. The patient underwent urgent chest tube insertion and supportive management, with gradual improvement in their respiratory status over the following weeks. Standard treatment for measles includes supportive therapy with hydration, antipyretics, and high-dose vitamin A to reduce complications. Antibiotics and respiratory support are required for secondary bacterial infections or severe pneumonia. This patient required oxygen therapy, antibiotics, and chest tube insertion due to pneumothorax. This rare but life-threatening complication of measles underscores the importance of vaccination and vigilant monitoring of measles patients, even during the convalescent phase of illness.

Abstract Introduction Brain metastasis (BM) in non-small cell lung cancer (NSCLC) is still an important reason for morbidity and mortality despite the advances in cancer treatment. Using tyrosine kinase inhibitors against epidermal growth factor receptors (EGFR) mutations revolutionized NSCLC treatment. We investigated whether the presence of EGFR mutation influences survival in patients with lung adenocarcinoma with BM. Material and methods The data of the patients with pathological diagnoses of NSCLC and BM at tertiary hospitals were analyzed retrospectively in terms of survival. A total of 2554 patients diagnosed with NSCLC pathologically between 01 January 2010 and 01 January 2021 were identified. After the exclusion of patients with a lack of data, unknown EGFR mutation status, no brain metastasis, and additional malignancy 336 patients were included in the study. Results It was found that EGFR ( +) patients were more female dominant (48.6% vs 13.3% p < 0.0001) and were have less history of smoking (47.2% vs 87.1%, p < 0.0001) and were better survival (79.2% vs 92.8%). We found negativity of EGFR increased death risk by 1.700 times (95% CI 1.323–2.183, p < 0.0001) in univariate analysis and by 1.724 times (95% CI 1.251–2.377, p = 0.0001) in multivariate analysis. When overall survivals were compared estimated overall survival time of EGFR ( −) patients was 10.088 (95% CI 8.571–11.606) months and of EGFR ( +) patients was 11.829 months (95% CI 10.336–13.323) (p < 0.001). Conclusion EGFR positivity was associated with survival. Also, survival was significantly longer in EGFR-positive patients with brain metastases diagnosed with NSCLC.

Abstract Bronchiectasis due to previous tuberculosis is known to precede Mycobacterium avium (MAC) lung disease. Coronavirus disease 2019 (COVID-19) is an emerging infectious disease, and residual bronchiectasis following COVID-19 is common as well as tuberculosis. However, there have been no reports documenting MAC lung disease secondary to bronchiectasis post-COVID-19 until now. We present the case of an 84-year-old patient on steroid therapy for alveolar hemorrhage who developed COVID-19, resulting in residual bronchiectasis. Despite no evidence of chronic airway infection immediately prior to the COVID-19 infection, the patient developed pulmonary MAC disease 2 years later. This is the first report of MAC lung disease secondary to bronchiectasis following COVID-19. Similar cases are likely to occur in the future, necessitating caution.

Abstract Purpose Airway stents (AS) are a last-resort treatment for central airway obstructions when airway patency cannot be maintained above 50%, in patients unsuitable for surgery, or with recurrence after surgery. However, AS placement can cause complications, including life-threatening mucostasis, which is challenging to manage. Standard methods to prevent mucus retention often have limited efficacy. Dornase alfa, a mucolytic agent widely used in cystic fibrosis (CF) patients, has shown efficacy in secretion control in mechanically ventilated pediatric non-CF patients. This study evaluates the efficacy and safety of nebulized dornase alfa in managing AS-related life-threatening mucostasis. Results Fourteen patients (mean age 56.3 ± 15.6 years) with life-threatening mucostasis were identified among 255 stented patients (2017–2019). Eight had Y-shaped stents, and 6 had non-Y-shaped stents (5 hourglass and 1 OKI); 13 stents were placed for benign conditions and 1 for malignancy. Mucus grades (defined by Marchese et al.) and the number of bronchoscopies needed 6 months before and after dornase alfa were evaluated. Statistically significant decreases were observed in both mucus grades (2.36 ± 0.49 to 0.79 ± 0.59, p < 0.001) and the number of bronchoscopies per patient (3.21 ± 0.89 to 2.00 ± 1.04, p = 0.002). The shape of AS and the presence of bronchiectasis on thoracic computed tomography scans had no significant impact on mucostasis development. No side effects related to dornase alfa were observed. Conclusion Dornase alfa significantly reduced mucus burden and bronchoscopic interventions in AS-related life-threatening mucostasis, demonstrating its safety and efficacy for managing this complication.

Abstract Background Coughing is frequently linked to urinary incontinence (UI) in women. However, there is few information about its actual prevalence among women with chronic cough. There are some previous studies that link urinary incontinence to the occupational status. Aim of work To measure the prevalence of stress urinary incontinence and to identify the relationship between urinary incontinence and occupational status among female patients with chronic cough. Materials and methods A cross-sectional study was conducted on 80 female patients presented with chronic cough of any cause, and all patients were interviewed using a structured questionnaire that included personal, occupational, chronic cough, and urinary incontinence questionnaire. General and local examination were done. Results Out of 80 patients, 55% were found to have stress urinary incontinence. Gastroesophageal reflux disease (GERD) was the most prevalent cause of chronic cough (48.8%) followed by bronchial asthma (22.5%). Most of the studied patients (90.9%) reported that leaking of urine interferes with their quality of life. The frequency of UI among working females was significantly higher than nonworkers. Occupations requiring physical activity had significantly higher frequency of UI than those without. Other environmental work conditions as unclean or uncomfortable workplaces had no significant relationship with UI. Menopause patients had 2.8 times higher risk to develop UI. The mean age, mean number of parities, vaginal delivery, median duration of cough, cough severity index, and cough visual analogue scale were significantly higher in UI patients. The logistic regression was performed to test effects of different risk factors on UI. Results indicated that age, type of occupations according to physical activity, and cough severity index were independently statistically significant risk factors for UI in female patients with chronic cough. Conclusion UI is common in female patients with chronic cough (55%). Age, type of occupations according to physical activity, and cough severity index were independently significant risk factors for UI in female patients with chronic cough.

Abstract Background Acute exacerbation of obstructive airway diseases is the most frequent acute clinical scenario in ER in chest hospitals. There are limited objective and continuous real-time measures of acute exacerbation severity to guide treatment. Pulse oximeter plethysmograph wave is an objective bedside measure of change in blood volume beneath the probe and was found to correlate well with pulsus paradoxus which is one of the signs of respiratory distress. Objective To assess using pulse oximeter plethysmograph to monitor severity and response to therapy in patients with acute exacerbation of obstructive airway diseases. Patients and methods This study was a prospective cross-sectional study conducted on 100 patients, 45 patients with bronchial asthma exacerbation and 55 patients with COPD exacerbation, who attended the 23 July Chest Hospital ER from January 2023 to September 2023. Baseline variation (BLV) of pulse oximeter waveform of these patients was assessed qualitatively (visually) and quantitatively (maximum distance from baseline in mm) during the course of management in ER, and results correlated with severity indices and outcome. Results On ER admission, BLV was 3–13 mm with a median IQR 5 (4–7 mm) in 100 patients. There was a significant correlation between quantitative BLV and other signs of exacerbation severity (heart rate, respiratory rate, pulsus paradoxus and AAIRS for asthma, and Borg score for COPD). Forty patients improved under treatment and were discharged home, while 60 patients showed no improvement and required admission to hospital. Changes in BLV correlated well with the response to therapy and outcome in all patients. BLVs were recognizable by visual assessment as well. Conclusion BLV of plethysmograph wave is a reliable simple, non-invasive, and real-time tool in assessing severity and response to treatment of acute exacerbation of obstructive air way diseases. It is thus useful in monitoring and triaging these patients in ER and critical care settings.

Abstract Background and objectives Chronic obstructive pulmonary disease (COPD) is a prevalent respiratory condition, often complicated by frequent exacerbations and increased mortality risk. COPD patients also had a higher risk for developing diabetes mellites. Recently, the studies showed promising utility of HbA1C in identifying patients at heightened risk of critical illnesses. This study evaluated the diagnostic and prognostic value of glycated hemoglobin (HbA1c) in predicting COPD exacerbation and short-term mortality. Methods A prospective cohort study involved 184 COPD patients. Patients were categorized as either stable or experiencing an acute exacerbation. Demographic and laboratory data, including HbA1c levels, were collected. Results HbA1c levels were significantly elevated in COPD patients experiencing exacerbations. Factors influencing HbA1c levels included lower oxygen saturation upon admission, use of home oxygen, lymphocyte count, CRP levels, diabetes, and ischemic heart disease (IHD). HbA1c emerged as a strong predictor of both COPD exacerbation and short-term mortality. In the unadjusted model, HbA1c was associated with an increased risk of exacerbation (OR = 1.59, p = 0.001) and remained significant after adjusting for other variables (OR = 2.25, p = 0.03). Similarly, HbA1c was a significant predictor of mortality in both the unadjusted (OR = 1.44, p = 0.001) and adjusted models (OR = 1.66, p = 0.001). Notably, the use of home oxygen was associated with a lower risk of both exacerbation and mortality. Other risk factors for exacerbation included lower oxygen saturation, male sex, IHD, and a history of previous exacerbations. The mortality rate was significantly higher in patients who had experienced recent exacerbations. Conclusion Elevated HbA1c levels were consistently associated with a higher risk of adverse outcomes, even after adjusting for other significant factors. This highlights the importance of routine HbA1c monitoring in COPD management, particularly in patients with a history of exacerbations or comorbid conditions like diabetes and ischemic heart disease. Additionally, the protective effect of home oxygen therapy against exacerbations and mortality suggests it should be considered as a key component in the management strategy for high-risk COPD patients.

Abstract Background Bronchoscopists worldwide still prefer to use 2% lignocaine as the preferred topical airway anesthetic. The minimum concentration of lignocaine used during flexible bronchoscopy to prevent uncontrolled coughing is still unclear. This double-blinded, randomized controlled trial compared the efficacy of 1% and 2% lignocaine solutions for topical anesthesia during routine flexible bronchoscopy procedures. Five hundred patients were randomized to receive either 1% or 2% lignocaine. For topical airway anaesthesia, lignocaine was administered in aliquots of 2 ml each in a spray-as-you-go technique. The study’s primary outcome was the assessment of cough objectively by the consultant proceduralist, respiratory nurse, and assisting respiratory therapist. The subjective cough evaluation was taken from the patient using the cough visual analog score (VAS). The key secondary outcomes investigated were the total lignocaine dose, complications due to lignocaine administration, overall procedure satisfaction assessed by bronchoscopist (VAS), and patient (VAS) pain score. Results The cough VAS scores, as assessed by patients in both groups (2% vs. 1%), were similar (28.4 vs. 28.0 [p − 0.997]). The cough VAS scores evaluated by the bronchoscopist (31.4 vs. 34.5 [p − 0.116]), respiratory nurse (31.3 vs. 34.3 [p − 0.182]), and therapist (31.7 vs. 34.3 [p − 0.209]) were slightly higher in the 1% arm. The pain ratings by the patient were similar between the two groups (0.82 vs. 0.92 [p − 0.135]). The overall satisfaction of bronchoscopists was slightly higher in the 1% arm (35.01) vs. 2% arm (32.18) [p − 0.167]. The cumulative dose in the 1% lignocaine arm was 253 mg compared to 490 mg in the 2% lignocaine arm. There was no adverse event related to lignocaine overdose in either arm. Conclusions One percent of lignocaine was found to be as effective as 2% lignocaine for topical anesthesia during routine flexible bronchoscopy procedures, and it was achieved at a significantly lower dose of lignocaine in the 1% arm. So, in flexible bronchoscopy, we suggest 1% lignocaine as the preferred topical airway anesthetic agent over 2% lignocaine.

Abstract Background Pancreaticopleural fistula (PPF) is an uncommon and dangerous complication of pancreatic disease and can lead to significant morbidity due to the presence of pleural effusion usually on the left side. PPF is an abnormal communication between the pancreatic duct and the pleural cavity, which occurs in patients with chronic pancreatitis or pancreatic pseudocysts. Case presentation This case report chronicles an unusual presentation of PPF in a male in his 60 s, highlighting the diagnostic challenges and the critical need for early recognition and appropriate management. The diagnosis was confirmed through a comprehensive diagnostic workup, including imaging studies and pleural fluid analysis. The patient was successfully managed with a combination of chest tube drainage, Octreotide therapy, and endoscopic intervention. Conclusion Pancreaticopleural fistula (PPF) should be considered a possible diagnosis in patients who present with an unexplained recurrent pleural effusion and have a history of pancreatic illness.

Abstract Background Tubercular lymphadenitis (TBLN) is the most common extrapulmonary tuberculosis (EPTB) followed by tubercular pleural effusion (TPE). The bacteriological confirmation to diagnose EPTB is more difficult due to its paucibacillary nature often leading to delay or misdiagnosis. The role of the CBNAAT test for the diagnosis of EPTB is highly variable among different populations. Hence, the aim of the present study was to evaluate the role of CBNAAT in the diagnosis of EPTB in a tertiary care center in north India. Methods This was a cross-sectional study conducted in the 100 stable patients of EPTB (55 TPE and 45 TBLN) who came to the Respiratory Medicine Department in MMMC&H, Solan, India. The total duration of the study was eighteen months from April 2021 to September 2022. Fine needle aspirate and pleural fluid samples were collected from all suspected TPE and TBLN patients respectively and were subjected to CBNAAT investigation. All other recommended investigations used for diagnosis of TBLN and TPE were also performed including ZN stain, FNAC, biochemical analysis of pleural fluid, Mantoux test, radiological imaging, and other routine investigations. The data analysis was done using SPSS version 20 software. Results Out of 100 patients of EPTB, 55 were TPE, and 45 were TBLN patients. The positivity of CBNAAT was higher in TBLN patients (57.8%) as compared to TPE (23.7%) patients. The correlation between CBNAAT and ZN stain was statistically significant in both TBLN (p = 0.008) and TPE (p = 0.001) patients. The correlation of CBNAAT with FNAC, duration of illness, erythrocyte sedimentation rate (ESR), and Mantoux were all statistically significant (p < 0.05). Conclusion Our study finding showed higher positivity of CBNAAT in the TBLN as compared to that in patients of TPE. The positivity of CBNAAT in the TBLN patients was higher in pus and cheesy FNAC samples, Mantoux-positive patients, and those with high ESR value.

Abstract Background The 2019 coronavirus illness (COVID-19) has caused significant disruption on a worldwide scale. With several recent studies observing the rise of thyroid problems in afflicted individuals, the influence of COVID-19 on thyroid function is receiving more attention. This study aims to determine the prevalence of thyroid dysfunction in COVID patients. Methods We evaluated thyroid function tests (TFTs) in 129 patients who were hospitalized to Zagazig University Hospitals with confirmed COVID-19 infection. Patients with pre-existing thyroid conditions or those on medications influencing (TFTs) were excluded. Serum levels of free thyroxine (FT4), thyrotropin (TSH), and free triiodothyronine (FT3) were measured on the first day of admission, followed by follow-up TFTs within the first six months, one year, and two years after discharge. Results We included 129 patients aged between 22 and 70 years, with 38 (29.5%) identified as male and 91 (70.5%) as female. Upon admission, (TFTs) were normal in 14.9% of patients. The findings also revealed 13.2% with subclinical hypothyroidism, 32.6% with subclinical hyperthyroidism, 6.2% with hypothyroidism, and 37.2% with hyperthyroidism. Two years after discharge, only 43.4% had normal TFTs, while 10.1% were being treated for hypothyroidism and 46.5% for hyperthyroidism. Conclusion This study emphasizes the complex interplay between COVID-19, thyroid function, and vaccination status. The results indicate that thyroid dysfunction specifically hyperthyroidism, subclinical hyperthyroidism, hypothyroidism, or subclinical hypothyroidism might be a frequent outcome for patients recovering from COVID-19, particularly in those who experienced more severe cases.

Abstract Background Idiopathic pulmonary fibrosis (IPF) is a chronic, progressive, and fatal disease of the lungs. It is characterized by pulmonary and extrapulmonary comorbidities. So far, little is known as regards the prevalence of cardiovascular comorbidities in IPF patients. This study aims to investigate the prevalence of cardiovascular comorbidities in patients with IPF and correlate it with different radiological and laboratory indices of disease severity. Methods This prospective case–control study was performed on 134 IPF patients above 18 years. Diagnosis of IPF was based on diagnostic radiologic criteria addressed by ATS guidelines. Patients were recruited from the Pulmonology Department, Assiut University Hospitals, from June 2023 to June 2024. Cardiac comorbidities were assessed by ECG and echocardiography. All patients had C-reactive protein (CRP), Krebs von den Lungen-6 (KL-6), and lipid profile including cholesterol level, triglyceride level, HDL-cholesterol level, and LDL-cholesterol level measured. Patients were divided into two groups: IPF patients with cardiovascular comorbidities and IPF patients without cardiovascular comorbidities. Comparison between both groups as regards clinical, radiological, and laboratory criteria was carried out. Results The studied group consists predominantly of females (65%). Sixty out of the 134 documented IPF patients had cardiovascular comorbidities (44.7%), cardiomyopathy (mean ± SD: 43.63 ± 10.56), pulmonary hypertension (mean ± SD: 41.67 ± 15.32), ECG-ischemic changes (40.0%), and atrial fibrillation (13.3%). IPF patients with cardiovascular comorbidities vs. patients without had higher radiological HRCT total fibrosis score TFS (P value < 0.001). As regards laboratory serum biomarkers, the group with comorbidities showed significantly higher CRP, KL-6, cholesterol level, triglyceride level, and LDL-cholesterol level (P value < 0.001). Box plot analysis demonstrated significantly higher KL-6 serum level among IPF patients with cardiovascular comorbidities. Sensitivity 90.0%, specificity 94.6%, and accuracy 92.5% were associated with a cutoff value of KL-6 ≥ 299 for prediction of associated cardiovascular comorbidities among the studied IPF group. Conclusions Dyslipidemia and cardiovascular comorbidities were detected in a large group of IPF patients. These comorbidities were associated with a high HRCT TFS score. High serum levels of CRP and KL-6 were predictors of associated cardiovascular comorbidities in IPF. Trial registration ClinicalTrials.gov. NCT06539962.

Abstract Background IPF is a chronic disease with impaired diaphragmatic function. In the vast majority of patients, lung function gradually deteriorates until intractable respiratory failure occurs. Aim of work To assess diaphragmatic ultrasound in IPF patients and its relation to functional parameters. Subjects and methods This study used a case–control design and involved IPF patients who were either attending an outpatient clinic or admitted to a ward at Ain Shams University Hospitals and Abbassia Chest Hospital. Forty-five participants were included and split up into 3 groups: group A: 15 IPF cases suffering from hypoxia. Group B: 15 IPF patients without hypoxia or respiratory failure. Group C: 15 healthy participants as controls. Result Groups A and B had considerably decreased diaphragm excursion (QB), thickness of diaphragm at the end of inspiration, diaphragm thickness fraction, and diaphragm thickness fraction % when compared to the control group. Patients' diaphragm excursion during deep breathing was significantly smaller in group A than it was in the controls. The diaphragm excursion (QB and DB), the thickness of the diaphragm at the end of inspiration, the thickness fraction, and the fraction % were positively associated with FVC, FEF 25–75, FEV1, 6MWT, the O2 sat before, the O2 sat after, and the O2 at RA, while they were negatively correlated with FEV1/FVC. There was no difference between groups in diaphragm thickness at the end of expiration. Conclusion Diaphragmatic ultrasound parameters demonstrated strong correlations with pulmonary function parameters, 6-min walk test, and oxygen saturation levels.

Abstract Background Post-extubation stridor indicates the presence of laryngeal edema. The documented occurrence of post-extubation airway blockage ranges from 4 to 37%. Aim To evaluate the effectiveness of sonar assessment of laryngeal air column width difference to predict post-extubation upper airway obstruction and its relation to cuff leak volume. Patients and methods This was an observational, descriptive cross-sectional study, conducted on 48 mechanically ventilated patients fulfilling weaning criteria at the ICU of Chest Department, Faculty of Medicine, Zagazig University, from July 2022 to March 2023. Results A statistically insignificant variance was observed among COPD, ILD, overlap (OSA-COPD), pneumonia, aspiration pneumonia, and PE regarding laryngeal air column width difference (LACWD), while a statistically significant variance was observed among COPD, ILD, overlap (OSA-COPD), pneumonia, aspiration pneumonia, and PE regarding CLV; there was no correlation among cuff leak volume and LACWD, and there were 40 patients (83.3%) who had no post-intubation upper air way obstruction and 8 patients (16.7%) had post-intubation upper airway obstruction: 4 of them (8.3%) had success weaning, and 4 (8.3%) had failed weaning; and at cutoff value 140 ml, cuff leak volume had sensitivity of 100% and specificity of 97.5% with significance for prediction of stridor, and at cutoff value 1.15 mm, LACWD had sensitivity of 87.5% and specificity of 67.5% with significance for prediction of stridor. Conclusion Cuff leak volume and ultrasound-guided LACWD effectively predict post-extubation upper airway obstruction, suggesting their integration into institutional extubation protocols.

Abstract Background Dental students face a potential risk of COVID-19 exposure due to close patient contact and aerosol-generating procedures. This study explores the frequency of COVID-19 infection among Iranian dental students in 2022 following different vaccination doses. Methods A cross-sectional study was used to collect self-reported COVID-19 status. A total of 261 dental students volunteered to participate in the study. A total of 252 valid forms were gathered, with a response rate of 96.55%. Data analysis was performed using descriptive statistics, mean and standard deviation, and chi-square and Fisher exact tests by Spss17 (Chicago, USA) software. Results The rate of COVID-19 infection significantly decreased after the first and third doses of vaccination. The rate of COVID-19 infection was not very different after the first, second, and third doses of the vaccine according to the type of vaccine. Despite no significant difference in COVID-19 infection rates between genders, study years, or vaccine types (excluding AstraZeneca), participants who received the AstraZeneca vaccine experienced more serious side effects compared to those who received other vaccines. Conclusion Vaccination appeared to reduce the rate of COVID-19 infection among dental students and may have decreased the duration of infection following different vaccine doses. There was no significant difference in infection rates based on the type of vaccine received. Further research is needed to investigate the potential side effects and long-term effectiveness of COVID-19 vaccines.