September-December 2021
Page Nos. 273-371
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National commission for allied and health-care profession: What does it mean for respiratory therapy in India? p. 273
Madhuragauri Shevade, Jithin K Sreedharan, Manjush Karthika,
DOI:10.4103/ijrc.ijrc_96_21
COVID-19 and lung cancer: Strengthening the prevention component and improving the prognosis p. 276
Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava
DOI:10.4103/ijrc.ijrc_2_21
The coronavirus disease-2019 (COVID-19) pandemic overwhelmed health-care delivery systems owing to the significant morbidity and mortality. Lung cancer in the year 2020 alone has accounted for more than 2.2 million new cases and 1.8 million deaths across the globe. The purpose of the current review is to explore the impact of COVID-19 on lung cancer and to identify measures that can improve the prognosis of cancer patients during the ongoing COVID-19 pandemic. An extensive search related to the topic was carried out in the PubMed and World Health Organization website. Relevant research articles focusing on COVID-19 and lung cancer published between April 2020 and June 2021 were included in the review. Forty-five studies similar to the current study objectives were identified initially. Among them, five were excluded due to unavailability of the complete version of the articles. Overall, forty articles were selected based on the suitability with current review objectives. Keywords used in the search include COVID-19 and Lung cancer in the title alone only. It has been estimated that patients with lung cancer will have a significantly higher risk of an adverse outcome, if they acquire COVID-19 infection. National bodies across multiple nations have released recommendations for both prevention and optimal management of COVID-19 infection among known lung cancer patients. To conclude, the COVID-19 pandemic has significantly affected patients with lung cancer. Owing to the emergence of evidence of poor prognosis of infection among lung cancer patients, there is an indispensable need to adopt a multidisciplinary treatment approach.
Exploring the critical thinking skills of respiratory care students and faculty p. 280
Bshayer Ramadan Alhamad, Genevieve Pinto Zipp
Background: Critical thinking is an essential skill for respiratory therapists to provide competent patient care. However, limited evidence of respiratory care students' critical thinking levels and no empirical evidence assessing that of respiratory care faculty exists. This study aims to assess the overall critical thinking levels of respiratory care students and faculty, determine whether faculty have stronger overall critical thinking skills than students, and investigate students' and faculty's perceptions regarding what critical thinking is and how it develops. Methods: An E-mail invitation was sent to all accredited US respiratory care education program directors asking for their participation and forwarding the solicitation letter to students and faculty. Participants completed a two-section online survey first requesting demographic information and presenting three open-ended questions and then providing the health sciences reasoning test (HSRT) to assess participants' critical thinking. Quantitative data were analyzed using descriptive statistics and one-tailed independent t-test (P < 0.05); content analysis was used for qualitative data. IRB approval was obtained. Results: Twenty-two students (12 females and in associate degree programs) and 20 faculty (13 females, 9 with a master's) completed the HSRT. Students demonstrated moderate overall critical thinking ability (17.81 ± 4.19), whereas faculty had a statistically stronger level (21.65 ± 5.41) than students (P = 0.007). Qualitative data demonstrated participants' use of themes (e.g., problem-solving) identified in the literature to define critical thinking, reported faculty role (e.g., mentor) in promoting students' critical thinking, and presented educational strategies (e.g., case studies) for fostering students' critical thinking. Conclusions: This study found faculty displayed stronger overall critical thinking skills than students. It is imperative for respiratory care programs and faculty to develop further students' critical thinking levels from moderate to advanced, as recommended for the competencies specified in the American Association for Respiratory Care 2015 and Beyond report.
Nutrition therapy in patients requiring noninvasive ventilation in the intensive care unit: Feasibility, tolerance, and complications p. 289
Gaurav Sharma, Ramesh Venkataraman, Senthilkumar Rajagopal, Nagarajan Ramakrishnan, Babu K Abraham, Raymond Dominic Savio
Background: Patients requiring noninvasive ventilation (NIV) in the intensive care unit (ICU) are likely to have a high prevalence of malnutrition. Nutrition provision in these patients is of utmost importance; however, data on its feasibility, tolerance, and complications are largely unavailable. Objective: The objective of the study was to assess the prevalence of malnutrition in patients requiring NIV in the ICU and to analyze feasibility, tolerance, and complications of nutrition therapy in this population. Methods: This was a prospective, observational study of consecutive patients requiring NIV admitted to the multidisciplinary ICU of a tertiary care, teaching hospital between April 2017 and November 2017. Baseline nutrition status was assessed using subjective global assessment (SGA). Nutrition requirement calculation and prescription were standardized. All included patients were monitored for pattern of nutrition provision, adequacy of delivery tolerance, and complications. Relevant outcomes such as intubation rates, ICU length of stay (LOS), and mortality were also noted. Results: A total of 34 patients were included in the study. Seventy-six percent of patients (26 out of 34 patients) were malnourished as determined by SGA. The mean Acute Physiology, Age and Chronic Health Evaluation II score was 15.1 ± 6.9. The average time for feed initiation was 12.4 h, and the most common reason for the delay (in 43%) was an impending intubation. The mean percentages of calorie and protein requirement that was delivered by day 3 were 67.2% and 48.3%, respectively. Thirteen patients (38.2%) required continuous nasogastric (NG) feeding, while the others could be fed orally. In 14 patients (41.1%), we were able to achieve 80% or more of target calorie requirement by day 3, and among these patients, the mean percentage of target protein intake that could be achieved was 66.6% by day 3. Feed intolerance was observed only in three patients. One patient had an inadvertent dislodgement of NG tube. Six patients (17.6%) required intubation and three (8.8%) died. Mean ICU LOS was 5.6 ± 3.9 days. Conclusion: Patients requiring NIV in the ICU have a high prevalence of malnourishment. Protocol-driven nutrition delivery is feasible in this population and is well tolerated.
Effect of blow bottle device and flutter on functional capacity, dyspnea, fatigue, and peak expiratory flow rate in mild-to-moderate COPD patients: A comparative study p. 294
Samaradnyi Hichkad, BR Ganesh
Background: Chronic obstructive pulmonary disease (COPD) is expected to rank third among the sixth largest leading causes of death by 2020 and sixth most debilitating condition. Positive expiratory pressure techniques such as flutter and blow bottle devices are usually used to improve respiratory function. Objective: The objective of this study is to compare the effect of blow bottle device and flutter device on functional capacity, dyspnea, fatigue, and peak expiratory flow rate (PEFR) in participants with mild-to-moderate COPD. Patients and Methods: Forty-five participants, between 40 and 70 years were screened for the study. Of these, 32 participants were included and 27 completed the study. They were classified into two groups. Group A was given blow bottle device and Group B flutter device. A 1-week intervention protocol was given to the participants. Results: There was a significant postintervention improvement in mean walking distance in both Group A and Group B, (128.07 ± 15.48 m to 141.53 ± 16.75 m, 163.92 ± 48.2 m to 177.64 ± 55.3 m), respectively, and in PEFR ([Group A 180 ± 83.46 L/min to 195.76 ± 92.91 L/min and in Group B 138.57 ± 39.39 L/min to 158.57 ± 33.30 L/min]). Dyspnea and fatigue decreased significantly postintervention in both groups. Conclusion: Both blow bottle and flutter devices are effective as adjunct therapy in the improvement of functional capacity, dyspnea, fatigue, and PEFR in participants with mild-to-moderate COPD. Flutter device is more effective in improving functional capacity, dyspnea, and fatigue, whereas the blow bottle device is more effective in increasing PEFR.
Etiology and risk factors for late antibiotic de-escalation and their effect on intensive care unit outcome p. 299
Anirban Hom Choudhuri, Bhuvna Ahuja, Sakshi Duggal, Kapil Dev Soni, Rajeev Uppal
Background: Timely antibiotic de-escalation is essential in intensive care unit (ICU) to prevent the development of antibiotic resistance. This study was undertaken to identify the causes and observe the effects of late antibiotic de-escalation on mortality, length of stay, duration of mechanical ventilation, antibiotic-associated adverse effects, incidence of new infections, and growth of drug-resistant organisms in ICU. Methods: This retrospective study was conducted in a university hospital. A total of 76 consecutively admitted ICU patients were included after retrieving all information from the hospital database and obviating the need for IEC approval. All the enrolled patients had antibiotics initiated and de-escalated in ICU. Those patients for whom antibiotics were initiated before ICU admission were enrolled if their antibiotic prescription was unchanged on ICU admission. Patients with antibiotic de-escalation outside ICU were excluded. The two groups: N-antibiotic de-escalation <8 days and L-antibiotic de-escalation ≥8 days after ICU admission were compared with respect to all variables and analyzed using software R. Results: Of 76 patients, 41 (53.9%) were N and 35 (46.1%) were L. The mean antibiotic duration was 6 ± 1.5 versus 11 ± 3.4 days (N vs. L; P = 0.04). Prior antibiotic administration within 30 days was 6 versus 12 (N vs. L; P = 0.03). More incidences of "new infections" and drug-resistant organisms occurred in L (19.5% vs. 34.2%; P = 0.04 and 9.7% vs. 25.8%; P = 0.02, respectively). Prior antibiotic administration was independently associated with higher mortality risk in L (odds ratio – 2.34; confidence interval – 1.45–3.48; P = 0.01) and caused greater mortality in L (P = 0.03). Conclusions: Late antibiotic de-escalation in ICU was caused primarily due to persistence of infection and was associated with higher incidence of "new infections" and drug-resistant organisms and higher mortality in patients receiving antibiotics in the preceding 30 days.
An assessment of various phenotypes of chronic obstructive pulmonary disease p. 305
Devendra Singh, Ramakant Dixit, Neeraj Gupta, Hasha Thankam Somson, Akhilesh Verma, Himanshu Mittal
Context: Chronic obstructive pulmonary disease (COPD) is a multifactorial and heterogeneous disease. To approach this heterogeneity, an attempt to group patients with similar characteristics that could be associated with a differential clinical outcome has been done by using the term clinical phenotype. Aim: This study aimed to classify phenotypes of COPD, assess and compare demography, assess and compare functional status and comorbidities. Patients and Methods: A hundred stable COPD patients were studied to identify various phenotypes of COPD, clinical assessment (modified Medical Research Council grading), functional assessment (6-min walk test), spirometry (fraction of exhaled breath nitric oxide, diffusing capacity for carbon monoxide) and radiological assessment (high-resolution computerized tomography, echocardiography) and screening for obstructive sleep apnea by Berlin questionnaire. Chi-square test/Fisher's exact test was used for the analysis of qualitative data. Results: The mean age of subjects was 60.8 ± 9.2 years with male-to-female ratio 9:1. Out of total 100 COPD patients, 45% had emphysema phenotype, 15% had COPD with bronchiectasis, and 20% each had asthma COPD overlap and chronic bronchitis. COPD phenotype was most common in age group 56–65 years. Emphysema patients (48.6%) were underweight and obesity was found to be most common in chronic bronchitis (30%). Emphysema patients (91%) had maximum exacerbation during the past 1 year with mean 6-min walk distance (158.7 m) and mean forced expiratory volume in 1% was 37.5. Conclusion: This is the first study in India which provides comparative categorizations of the phenotypic subgroups of COPD on various parameters.
Comparative assessment of depression, quality of sleep, and respiratory functions among tuberculosis patients with their nontuberculosis family contacts p. 312
Afreen Begum H. Itagi, Amudharaj Dharmalingam, GY Yunus, Senthil M Velou, Senthil Kumar Subramanian, L Sundareswaran
Context: Tuberculosis (TB) patients may present depression as comorbidity. This presents great challenges including the stigma of increased risk of developing TB in tackling such patients. Aims: The main aim of the study was to assess the lung function, sleep quality, and extent of depression in TB patients as compared to non-TB family contacts. Methods: TB patients and their family contacts (60 each) stopping by specialized directly observed therapy short-course center at a tertiary care hospital were assessed for depression and quality of sleep. Pulmonary functions were analyzed by spirometry. Descriptive statistics and t-tests were applied using SPSS version 19.0. P ≤ 0.05 was considered significant. Results: Depression with a significantly higher mean Patient Health Questionnaire-9 score was more prevalent among TB patients (73.3%) when compared to their family contacts (46.7%). TB patients presented with significantly higher levels of mean global Pittsburgh Sleep Quality Index score (9.56 ± 3.97) compared to their non-TB family contacts (4.36 ± 2.07), indicating a poorer sleep quality and also the sleep disturbance and daytime dysfunction were significantly more in TB patients (P = 0.000). The lung function measures were reduced in TB patients, and the difference was significant compared to their non-TB family contacts. Conclusions: The present study shows that TB patients have a poor quality of sleep, higher depression levels, and reduced lung functions compared to their non-TB family contacts. This calls for well-organized screening strategies to screen the in-apparent symptoms of adverse mental conditions among TB patients and their family caregivers/contacts with aid of mental health professionals to enable better management of this population.
Role of sodium bicarbonate as adjuvant treatment of nonsevere computed tomography-identified COVID-19 pneumonia: A preliminary report p. 318
Mohammad Khairy El-Badrawy, Abdelbaset Mohamed Saleh, Adel El-Badrawy, Tamer Ali El-Hadidy, Mohamed Abd Ellatif, Rehab Ahmad Elmorsey, Ahmed A Shokeir
Background: Coronaviruses are classified as pH dependent. Alkaline media induced by sodium bicarbonate (SB) could impede viral entry into cells. We aimed to study the possible role of SB as an adjuvant treatment of nonsevere COVID-19 pneumonia. Methods: The study included 182 adults with confirmed nonsevere COVID-19 and chest computed tomography (CT) pneumonia; 127 assigned as study received conventional treatment plus adjuvant SB inhalation and nasal drops, as well as 55 assigned as control treated by conventional treatment only. Clinical and radiological assessments using chest CT score specific for COVID-19 were done at days 0 and 30. Results: Both the groups were comparable regarding demographic, clinical, and radiological characteristics. Clinical recovery was reported in 43/127 (33.9%) and 10/55 (18.2%) of the study and control groups, respectively (P = 0.03). The mean ± standard deviation time to clinical improvement was 3.31 ± 0.99 and 9.79 ± 6.29 days for the study and control groups, respectively (P < 0.001). The median of the total chest CT score was reduced from 10 (4–15) to 3 (0–19) in the study group (P = 0.000) and from 13 (2–15) to 11 (2–19) in the control group (P = 0.53) on days 0 and 30, respectively. Conclusions: SB could be a possible adjuvant therapy for selected patients with nonsevere COVID-19 pneumonia.
Pleural fluid cholesterol: A promising marker to differentiate transudates and exudates p. 326
Nitin Rustogi, Harish Gupta
Background: Categorization of pleural effusion into exudates and transudates is crucial for diagnosis and management. Light's criteria are the most commonly used method but has its own pitfalls. Objective: The objective is to study diagnostic value of pleural fluid cholesterol (pfCHOL) in differentiating transudative from exudative pleural effusions. Patients and Methods: A total of 101 subjects presenting with pleural effusion in the outpatient and emergency departments of a tertiary hospital were enrolled in the observational study. Pleural fluid protein, lactate dehydrogenase, adenosine deaminase, and pfCHOL were analyzed from pleural fluid samples obtained by diagnostic thoracocentesis. Pleural fluid was classified into transudates and exudates based on the etiology (gold standard) against which Light's criteria and pfCHOL values were compared with appropriate statistical methods. Results: 74.26% were males. 46.53% were transudates as per the etiological diagnosis. According to the Light's criteria, 45.54% were transudates. With pfCHOL cut-off value of 1.16 mmol/L or 45 mg/dL, 44.55% were transudates. The transudates and exudates had a mean cholesterol level of 27.8 ± 7.84 mg/dl and 70.76 ± 22.35 mg/dL, respectively. A pfCHOL level of 45 mg/dl correctly identified 97.78% as transudates and 96.43% as exudates. Receiver operating characteristic analysis of pfCHol with a cut-off of 45 mg/dl showed a sensitivity (98.18%), specificity (95.65%) (P < 0.0001), area under curve 0.969, positive predictive value and negative predictive value of 96.4% and 97.8%, respectively. Conclusion: pfCHOL is a less complex, cost-effective, reliable diagnostic marker and is as good as the Light's criteria to differentiate transudates and exudates.
Pressure support ventilation in neonates – Is it safe? p. 330
Aathira Rajan, Gokul G Krishna, Leslie Edward Lewis
Introduction: Pressure support ventilation (PSV) is a common weaning mode in adults, but it is less familiar among the neonatal population due to lack of awareness and safety concerns associated with leaks around uncuffed endotracheal tube. There is limited evidence addressing this issue in the literature. Therefore, the study focuses on the safety of PSV among neonates. Subjects and Methods: The prospective observational study was done among 57 neonates (gestational age from 26 to 37 weeks) requiring mechanical ventilation. PSV mode was used 30 min before extubation and assessed for any changes in hemodynamic and ventilator parameters for two time points, during the initiation of PSV, and the end of 30 min of the trial. The incidence of reintubation within 72 h was also noted. Results: There were no wide variations in hemodynamic and ventilator parameters during the trial. The average heart rate, respiratory rate, and saturation of oxygen were noted to be 146 bpm, 54/min, and 95%, respectively. The average mean airway pressure was found to be 7.2 cm H2O during PSV. The reintubation rate was found to be 8.2%, with a mortality rate of 5.2%. Conclusion: The current study findings conclude that PSV in neonates can be used safely as an independent mode during weaning.
Does masimo signal extraction technique pulse-oximeter improve the detection rate of congenital heart diseases of newborn? - An observational study p. 336
Saranya Jayachandran, Laveena Diaz, Leslie Edward Lewis, Gokul G Krishna
Introduction: Congenital heart diseases (CHDs) are common congenital anomalies, which if left untreated account for higher mortality and morbidity. Early detection and surgical correction of CHDs are the best treatment measures. The current study aims to test whether Masimo signal extraction technique (SET) pulse-oximeter, which uses signal extraction technology improves the detection rate of CHDs with its overall sensitivity, specificity, and accuracy. Subjects and Methods: The current prospective, observational study was conducted at a tertiary medical center over a period of 2 years. All the neonates' pre- and post-ductal oxygen saturation along with clinical examination was performed within 24 h of life. Postductal reading of ≤ 95% and/or with difference between pre- and postductal of > 5% was considered to be positive for CHDs. Infants with clinical symptoms or test positive for pulse oximetry were referred for echocardiographic confirmation. Results: A total of 2213 infants were observed. Seventeen CHD cases were detected during the study period. Four hundred and fifteen infants tested positive with the pulse oximeter. Ten of them had minor or major CHD and two of the infants had critical CHD. The overall sensitivity of pulse oximetry screening was 70.59% (95% CI), specificity of 81.65%, and a diagnostic accuracy of 81% for any CHDs. Conclusion: Masimo SET pulse oximeter is a sensitive tool for detecting CHDs. A pulse oximeter in combination with clinical examination aids in the better detection rate of CHD. Echocardiography must be considered in all infants who test positive with pulse oximeter or any abnormal findings in the clinical examination.
Empyema thoracis in children: Can pleural fluid culture positivity affect the outcome? p. 341
Indra Kumar Sharma, Durgesh Kumar, Anshuman Tripathi
Background: Empyema thoracis in children continues to be a major problem with significant morbidity in developing countries despite recent advances in management. This study was aimed to evaluate the clinico-etiology and compare the outcomes of sterile and culture-positive pleural fluid empyema thoracis in North Indian children. Patients and Methods: A total of sixty admitted children satisfying the inclusion criteria were enrolled in the study from October 2018 to September 2020 with parental consent. Bacteriological etiology was confirmed by pleural fluid culture. Disease outcome was evaluated by duration of chest tube insertion, hospital stay, mortality, and successfully discharged patients. The outcomes were compared between patients with sterile and positive pleural fluid culture. Results: The average age of the patients was 4.72 ± 3.52 years with male preponderance (male/female ratio: 1.3:1). Forty-five percent of the patients were between 1 and 5 years. The most common predisposing factor was pneumonia. Fever and cough were the most common manifestations. Pleural fluid culture was positive in 28.3%, with Staphylococcus aureus being the most common organism isolated. Intercostal drainage (ICD) tube was used in 93.3% of the patients and was successful in 80%. The average period of ICD tube placement was 9 ± 4.18 days while hospital stay was 21 ± 9.12 days. Mortality was 1.7%. No statistical significant difference was found in outcomes between patients with sterile and culture-positive pleural fluid. Conclusions: S. aureus was the most common cause of empyema thoracis in this study. The high proportion of culture-negative specimens indicates that pleural fluid culture is not a satisfactory diagnostic tool to find the causative organism.
Successful lung clearing even after spontaneous pneumomediastinum and COVID-19 ARDS p. 346
Rakhee Sodhi Khanduri, Sushant Khanduri, Sandeep Kumar, Manvendra Garg, Kanupriya Bhatia
In severe COVID pneumonia, we have seen reports of patients suffering from spontaneous pneumomediastinum, as well as pneumothorax as a unique complication. Diffuse alveolar damage can be the etiology behind this. We report a case of a 51-year-old mountaineer female who had severe COVID pneumonia, developed air leaks, but her lung injury and scarring completely improved in 5 months.
Home management and self-monitoring in a patient with chronic asthma suffering from mild COVID-19 : A case report p. 349
Latika Rohilla, Chaitra Doddamadaiah, Vithal Malmande
Pneumocystis jirovecii pneumonia: A life-threatening infection of the immunocompromised p. 352
Rohon Das Roy, Subhayan Das Gupta
Pneumocystis pneumonia (PCP) is a fatal pulmonary infection caused by an ascomycetous fungus, Pneumocystis jirovecii. The infection is mostly seen in patients with underlying disease conditions that alter the host immune status. However, immunocompetent hosts may also be transiently infected with self-limiting mild lower respiratory tract infection. Diagnosis of PCP requires demonstration of cysts of Pneumocystis in the lungs of the patient. Although an open lung biopsy is the most reliable method, a bronchoalveolar lavage is always more practical and nearly as sensitive. We report a case of a 32-year-old human immunodeficiency virus (HIV)-infected woman who presented with a 2-month history of nonproductive cough, respiratory distress, and fever. Her sputum examination showed growth of Klebsiella pneumonia and was sensitive only to levofloxacin. No acid-fast organisms were demonstrated. High-resolution computerized tomography scan of the thorax showed consolidated airspaces bilaterally with ground-glass opacities. Her CD4 count was 110 cells/mm3. PCP was diagnosed by performing a Giemsa stain of bronchoalveolar lavage, which revealed cysts of P. jirovecii. Diagnosis was further confirmed by the elevated serum (1-3)-β-D glucan levels. She was started on co-trimoxazole and prednisolone, following which her symptoms gradually improved. PCP is one of the most common causes of HIV-associated mortality and a rapid diagnosis with an early initiation of treatment can significantly improve patient outcomes.
Unilateral pulmonary agenesis with mayer-rokitansky-kuster-hauser syndrome: A rare association p. 355
Amiya Pandey, Manoj Pandey, Hemant Kumar, Natasha
Unilateral pulmonary agenesis is a rare congenital condition characterized by the absence of one or both lungs. Most of the cases have unilateral presentation as bilateral agenesis does not support life. Simultaneous Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome also has very rare presentation. It is characterized by congenital aplasia of the uterus and the vagina with normal female karyotype (46XX). A 30-year-old female, presenting with dyspnea from last 6 months and amenorrhea for last 15 years was further evaluated with gynecological examination, contrast-enhanced computed tomography thorax with the abdomen and karyotyping. She was eventually diagnosed as a case of Type I pulmonary agenesis with Type I MRKH syndrome. K
Adenocarcinoma masquerading as cryptogenic organizing pneumonia: An unusual presentation p. 358
Nazia Mehfooz, Parvaiz Koul, Tajamul Shah, Sumyra Khursheed, Rafi Jan, Sonaulah Shah, Romana Hamid
A case of elderly female is presented who had both clinical and radiological features of Cryptogenic organizing pneumonia. The patient did not respond to medical treatment. Bronchoscopy and transbronchial lung biopsy were done . The case finally proved to be adenocarcinoma lung.
A rare case of cavitating lung disease p. 361
Rahul Kumar Gupta, Arjun Kumar, Mihir Gangakhedkar, Vipul Prakash, Lokesh Saini, Prakhar Sharma, Mukesh Bairwa
Pantoea rarely causes infection in human lungs. Genus Pantoea is a rare pathogen causing opportunistic human infection in clinical practice. Among seven species of this rare organism, Pantoea agglomerans is the most common species in humans and is often associated with an occupational disease. Clinically, it may present with wound infection, abscess, catheter infection, pneumonia, and urinary system infection in immunocompromised individuals. However, there are no case reports of P. agglomerans causing cavitating lung disease in the past. Here, we report a case of a 67-year-old immunocompetent female who presented with cavitating lung lesions on chest imaging which were found to be associated with P. agglomerans leading to fatal outcomes. We emphasize on the unusual presentation, its course in the hospital, and importance of early recognition of this emerging bacterial infection causing fulminant human infections even in immunocompetent individuals.
Nasopharyngeal swabbing for COVID-19 testing in children: Challenges and solutions p. 364
Satvinder Singh Bakshi, Thirunavukkarasu Arun Babu
T-piece for COVID-19 patients: Innovation in a time of crisis p. 366
Rajesh Kumar, Abhyuday Kumar, Neeraj Kumar, Amarjeet Kumar, Ajeet Kumar
Granulomatosis with polyangiitis and dengue fever: A rare association p. 368
COVID-19 pandemic: It is time to think for micro-electro-mechanical system-based bidirectional flow sensor p. 370
Neeraj Kumar, Amarjeet Kumar, Abhyuday Kumar