Septic Iliac vein thrombophlebitis with associated psoas abscess is a rare and severe entity, which diagnosis is challenging when no risk factor is clearly present. We are presenting a case of severe septic cavitary pulmonary emboli complicated with Acute Respiratory Distress Syndrome (ARDS) that evolved rapidly to respiratory distress and multi organ failure. A 61-year-old Hispanic male, had multiple emergency department visits due to back pain, being most of them intramuscular pain medications and steroids. In the history, he had back pain that worsened accompanied by poor mobility, generalized malaise, fever and chills. Computed tomography (CT) scan showed a paravertebral psoas abscess with L5 - S1 diskitis/spondylitis inflammatory changes, which was then later evidenced by a gallium study. Further imaging studies were done, showed bilateral cavitary lung lesions, consistent with septic emboli. Subsequent blood cultures were positive for Methicillin Resistant Staphylococcus Aureus (MRSA), for which a successful combined therapeutic regimen was used. Transthoracic and transesophageal echocardiogram were not suggestive of endocarditis. Staphylococcus aureus (SA) bacteremia is one of the most common serious bacterial infections with a high risk of metastatic complications, which makes this pathogen a unique one. The combination of factors iliac vein thrombophlebitis, psoas muscle abscess, diskitis/spondylitis with ARDS makes cavitary pulmonary disease a challenging perspective. After a 6-week antimicrobial treatment, full anticoagulation, his clinical condition and image findings improved, and he was recently admitted for physical rehabilitation. Major vessels thrombophlebitis should always be considered, when primary source of septic pulmonary emboli is not clear. This case illustrates the complexity of illness and complications that may arise from a source of infection as the one in this patient. Further therapeutic strategies were tailored accordingly.

The emergence of COVID-19 worldwide in an unprecedented pandemic. COVID-19 has a significant mortality, mostly from acute lung injury. We reviewed the available literature from China and Europe in regard to the behavior of SARS-Cov2 and ability to adhere to the cell wall [1,2]. The evidence based literature describes three component for the virus to grant entry to the target cells including Cathepsin B/L (the viral cap protein needed for initial connectivity to the cell wall), the angiotensin converting enzyme 2 and a low PH environment to allow the first connectivity of the virus to the cell wall [3]. The goal of our Case study was to prevent SARS- SARS-Cov2 from entering target cells by raising the airways PH using sodium bicarbonate inhalation. The sodium Bicarbonate inhalation (4.2% concentration) has been used safely in Cystic fibrosis (CF) patients with inspissated mucoid impaction [3,4] and in chloride inhalation toxicity by opposing the effect of the low PH induced by the insulting agent [4,5]. It has not been administered for COVID -19 patients particularly prior to this study. 

Fifty nine isolates belonging to six species of Enterococci namely, Enterococcus faecalis, Enterococcus faecium, Enterococcus raffinosus, Enterococcus durans, Enterococcus mundtiiand Enterococcus avium (n = 35, 15, 4, 3, 1 and 1 isolates, respectively) were obtained from different clinical specimens including urine, pus, blood, wound, sputum and synovial fluid. The highest numbers of Enterococci were recorded from the pus (20 isolates, 33.90%) followed by urine (12 isolates, 20.34%) while the lowest frequency was observed with synovial fluid samples (2 isolates, 3.39%). These isolates showed different multidrug resistant patterns with the lowest resistant for linezolid (n = 5, 8.48%), followed by teicoplanin (n = 14, 23.73%) and vancomycin (n = 20, 33.90%) while they exhibited the highest resistant against penicillin (n = 53, 89.83%), oxacillin (n = 50, 84.75%), erythromycin (n = 49, 83.05%) and streptomycin (n = 47, 79.66 %). On the other hand, a free living marine bacterium under isolation code ESRAA3010 was isolated from seawater samples obtained from the fishing area Masturah, Red Sea, Jeddah, Saudi Arabia. The phenotypic, chemotaxonomic, 16S rRNA gene analyses and phylogenetic data proved that isolate ESRAA3010 is very close to Bacillus subtilis and then it was designated as Bacillus subtilis ESRAA3010. It gave the highest antagonistic activity against all clinical Enterococcus faecalis, Enterococcus faecium, Enterococcus raffinosus, Enterococcus durans, Enterococcus mundtiiand Enterococcus avium isolates under study with minimum inhibitory concentration (MIC) ranged from 4 to 56 µg/mL, 4 to 12 µg/mL, 4 to 8 µg/mL, 4 to 8 µg/mL, 8 µg/mL and 4 µg/mL, respectively as well as minimum bactericidal concentration (MBC) (8 to 64 µg/mL, 4 to 16 µg/mL, 4 to 12 µg/mL, 4 to 16 µg/mL, 12 µg/mL and 8 µg/mL, respectively). Moreover it showed anti-proliferative activity against colon (HCT-116), liver (HepG-2), breast (MCF-7) and lung (A-549) carcinomas with IC50 equal to 39, 50, 75 and 19 µg/mL, respectively which indicates its prospective usage in the upcoming decades.

Today, there is a considerable increase in localizing adrenal bulks with the bringing radiologic diagnosis methods having high technology into use and improvement in diagnostic tests. Adrenal glands are vital tissues for the organism due to the hormones they secrete. Death is a natural result in the absence of adrenal cortex. Adrenal bulks can be seen with different clinical, laboratory and radiological data. These bulks are often benign and rarely malign. They can be functional or non-functional. Major treatment methods used fort he treatment of adrenal gland primary tumors or metastases are surgery, arterial embolisation, chemical ablation, radiofrequency ablation and radiotherapy [1-4]. Adrenal glands are one of the metastatic fields. In wide autopsy series, adrenal metastasis has been determined between the rates of 13-17% [5]. While unilateral metastasis is common, bilateral metastasis’ rate of incidence is between 4-20%. It has been stated that lung (35%), gastric (14%), esophageal (12%) and hepatobiliary (10%) primary carcinomas adrenal metastasis are prevalent most frequently [2]. Curative treatments are tested on patients having cancer with oligo metastasis limited with adrenal gland and primary source is under control because of the expectation of long-term survival, and the surgery is the first choice. These bulks can be treated with open and laparoscopic surrenalectomy in a curative way. It was reported in studies that overall survival was longer in resection of clinically isolated adrenal metastases when compared with nonsurgical therapy (including RFA, external beam radiotherapy, arterial embolization, radioembolization, chemical ablation, and cryoablation) [1,2,5,7]. Lo et al., found one-year survival as 73% and two-year survival as 40% in their study conducted on 52 patients having curative resection for solitary adrenal metastasis [3]. Tanvetyanon et al., demonstrated 5-year survival rates of 25% following resection of isolated synchronous adrenal metastases and reported 26% after resection of metachronous adrenal metastases in their study conducted on NSCLC patients developing solitary adrenal metastasis [4]. Conducted studies revealed that the rate of complication was 9-20% in patients having adrenalectomy for solitary adrenal metastasis [2-4,7]. In recent years, the use of radiotherapy, which is a treatment modality as effective as surgical resection, has become prevalent for the management of oligometastases. Today, three different modalities have been tested in the radiotherapy treatment of adrenal gland metastases. In the first one, total 50 Gy treatment dose with 3D-CRT as daily 2 Gy fraction dose is given [8]. The second one is IMRT implementations for adrenal gland metastases but it isn’t thought as suitable according to Practice Guidelines for Neuroendocrine Tumors published by NCCN in 2010. The third radiotherapy modality is stereotactic body radiotherapy (SBRT). SBRT implementations have started to be preferred today since they are completed in a few fractions in addition to that they show close results to surgery for primary tumors and metastases. Holy et al., implemented SBRT to patients having 13 solitary adrenal metastases with NSCLC at 5 fractions and between 20 and 40 Gy total doses. They found disease-free survival as median 12 months, overall survival as median 23 months and local control rate as 77% [9]. In SBRT implementations for different cancer types determined 30 adrenal metastases, Chawla et al., reported the rates of one-year survival, local control and distant metastasis as 44%, 55% and 13% respectively [10]. In Casamassima et al.,’s study on this issue, the rate of two-year local control was found as 90% [11]. Second degree toxicity was seen in none of the above mentioned studies according to the RTOG toxicity classification. Wardak et al., reported that the patient having lung cancer that they implemented SBRT for bilateral adrenal metastases developed adrenal insufficiency depending on SBRT [6]. Ippolito et al., Reported that adrenal insuffiency may be due to both the tumor and the local treatment [12]. Incidence of symptomatic adrenal insufficiency were reported 4% [2,13]. Casamassima et al and Onishi et al studies, two grade 2 adrenal insuffiencies were reported [11,14]. Consequently, when all these data were evaluated, it is seen that SBRT use has gradually become prevalent for patients not suitable for surgery because of comorbid disease, for patients having oligometastatic cancer that are not suitable for surgery since it has vital risk to resect or that refuse surgery. However, it hasn’t been clear yet that local control will be provided with how many total doses and which fraction schema. There is no agreement on the examination of the adrenal hormone axes because of the short length of life. Besides, it should be kept in mind that adrenal insufficiency can develop in patients implemented SBRT because of bilateral adrenal metastasis developing as synchronous or metachronous. The hormone levels of these patients need to be followed. More researches should be done to lighten this matter.  

Introduction: The HRMT (Human Resting Myofasial Tone) factor plays an important role to initiate the trigger the inflammation at the disease site in Ankylosing spondylitis (AS) as in all spondyloarthropathies. The incidence of fibromyalgia is higher in AS and a limiting factor to undergo the exercise program. Aim of the study: To know the effectiveness of soft tissue mobilisation in patients with Ankylosing Spondylitis when it used as an adjuncts to the conventional exercises. Methodology: 40 subjects were randomly assigned in to experimental and conventional group. Experimental group (n=20) received conventional exercises along with soft tissue mobilisation and the conventional group (n=20) received only conventional exercises (flexibility exercises, aerobic exercise and breathing exercise) for a period of 4 weeks, 5days/week. Results: The result of the study showed that both the conventional and experimental groups improved significantly in stiffness, pain and physical function aspects after treatment. However the experimental group had a greater change as compared to conventional group. Conclusion: The study demonstrates that soft tissue mobilisation has an effect when it used before the conventional exercise in patients with ankylosing spondylitis.

Oxygen therapy is the main supportive treatment in hypoxemic respiratory failure and has traditionally been delivered using low and high flow devices. However, the maximal flow rates that these devices can deliver are limited because of the insufficient heat and humidity provided to the gas administered. Low flow devices such as the nasal cannula, conventional face mask and reservoir bag deliver a flow rate of up to 15 L/min by administering more variable oxygen fractions (FiO2), depending on the patient’s respiratory pattern, peak inspiratory flow and characteristics of the devices. Conventional high flow devices, such as venturi type masks, utilize a constant flow of oxygen through precisely sized ports, entraining the ambient air, using the Bernoulli principle, providing a more constant inspired oxygen fraction. However, they are less tolerated than nasal cannulas because they are less comfortable and the insufficient humidification and heating of the gas delivered [1]. In the last two decades, new devices have been developed to administer high humidified and heated flow through a nasal cannula (HFNC) that also allows the delivery of oxygen with a known FiO2 up to 100%. In the literature, this technique has also been called mini CPAP (continuous positive airway pressure), transnasal insufflation, high nasal flow ventilation, high flow oxygen therapy, and high flow nasal cannula oxygen therapy [2]. It is considered that high flow nasal cannula has certain benefits compared to those of oxygen therapy previously detailed. HFNC manages a flow of more than 30 L/min, which is able to surpass the peak inspiratory flow of the patient, being able to reach values ​​between 60-80 L/min depending on the flow used. The gas source, which may be delivered by an air/oxygen blender, fans, or a flow generating turbine, is connected by an active humidifier to a nasal cannula and the FiO2 can be adjusted independently of the flow. From a clinical point of view, there is some confusion between venturi and high flow nasal cannula devices. In the literature, both have been considered as high flow oxygen therapy devices. In our opinion this is not appropriate because the high nasal cannula flow is much more than a simple system for administering oxygen therapy [3]. Venturi-type masks provide the patient with a gas mixture with a controlled FiO2, but do not exert additional benefits on the ventilator mechanics of the patient. Nevertheless, HFNC allows the delivery of a high flow, which can also add oxygen therapy, providing a series of physiological effects that imply an active treatment to respiratory failure. Effects related to HFNC include the following: 1. Delivery of higher and more stable FiO2 values, ​​because the flow delivered is greater than the patient’s inspiratory demand. 2. The anatomical dead space decreases by washing the nasopharynx, consequently increases alveolar ventilation. This improves the thoracoabdominal synchrony. 3. Respiratory work decreases because it acts as a mechanical stent in the airway and markedly attenuates inspiratory resistance. 4. The gas administered is warmed and humidified, improving mucociliar clearance, reducing the risk of atelectasis, improving ventilation perfusion and oxygenation ratio. 5. There is a CPAP-like effect. The dynamic positive espiratory airway pressure generated by HFNC reaches a value between 6-8cmH2o depending on the flow and the size of the cannula. This positive pressure distends the lungs and ensures their recruitment. 6. Pulmonary end-expiratory volume is higher with HFCN than with conventional high-flow oxygen therapy. 7. In addition, the technique is considered easy and simple for the medical staff and nurses, and can be used in different areas (emergency, hospitalization, critical care unit, weaning centers) and even at home [4]. Currently available evidence has demonstrated that HFNC therapy is an alternative for the treatment of acute hypoxemic respiratory failure, hypercapnic respiratory failure, acute heart failure, as rescue therapy preventive therapy in post-extubation respiratory failure and in specific conditions such as bronchoscopy [5]. We believe that high-flow nasal cannula treatment should not be confused with high flow oxygen therapy of venturi masks. According to detailed mechanisms of action, HFNC is not limited to being only an oxygen therapy system but also behaves as a true treatment that can be used in different clinical scenarios, generating physiological benefits that result in the reduction of respiratory work. In addition, in venturi type masks, the air is not humidified and complications such as dryness and nasal pain are common, generating a poor tolerance to oxygen therapy. The benefits of proper humidification and heating of the gas delivered with HFNC therapy allow better comfort and tolerance of the patient with easy adherence to the treatment. All this contributes to making HFNC be considered a technique of choice in patients with hypoxemic respiratory failure. The growth in its use associated with easy acceptance for patients and the expansion in its application show us that HFNC is a promising therapy.

The barium is often used in radiocontrast examinations of the digestive system because of mucosal absorption is limited. Massive barium aspiration is a rare complication, especially when there is no anatomic or neurological deficit. The depending on barium concentration can cause various lung effects. When the literature is reviewed, barium aspiration may be asymptomatic or lethal in massive amounts. Rarely, large amounts of barium sulphate are aspirated into the lung, there is no literature study how often this is happening. We present a case of massive barium aspiration in this subject. The case is related to a patient’s diagnostic esophagography who complaints swallowing problems. The massive barium aspiration couldn’t notice because of the absence of acute symptoms and surgical operation of gastrointestinal tract which the patient had undergone previously. When the patient applied our Pediatric Chest Diseases Polyclinic after three months, as a result of the examinations and deep research it was understood that the case was about massive barium aspiration. The patient was directed to our center because there was a radiological appearance of bone density signs on chest X-ray. Such a complaint was not reported by the family neighter in his biography, nor was written in the epicrisis. We will share acute and chronic changes in the lungs, diagnosis and treatment approaches of this case. The infant who has ileostomy was previously operated because of necrotizing enterocolitis. And also still has severe gastro-esophageal reflux and under conservative and medical treatment, a possible fundoplication surgery is planning.

Two of the most recent LABA/ICS combinations for treatment of persistent asthma are Fluticasone furoate/Vilanterol 92/22 µg (Ellipta) and Beclomethasone dipropionate/Formoterol 100/6 µg (Nexthaler). Objective: To compare once-daily Fluticasone/ Vilanterol combination with twice daily Beclomethasone/ Formoterol association in moderate asthma, in terms of quality of life and lung function. Methods: Fourty patients with moderate asthma treated with Beclomethasone/Formoterol 100/6 µg or Fluticasone/Vilanterol 92/22 µg. We revalued patients in terms of lung function and Asthma Control Test, at 4, 8 and 12 weeks to assess any differences between the two groups. After 4 weeks, thirty-one of the fourty patients were evaluated in terms of respiratory function at predetermined time intervals. Result: In patients treated with beclomethasone/formoterol FEV1 presented a mean value of 78% at the third visit and of 79.1% during the final check, compared with 74.5% and to 75.8% in patients in treatment with fluticasone/vilanterol (p 0.01). Mean values of IC and MMEF25-75% were higher in patients treated with beclomethasone/formoterol compared with fluticasone/vilanterol. For the dyspnea it was a difference at the third observation. For the nocturnal symptoms and the use of rescue drug there was a significant difference, except at the beginning. For the perception of control by patients, there was a difference in the two groups at the beginning, after 4 and 8 weeks. Total ACT score showed a significant difference after 4, 8 and 12 weeks. In the group treated with beclomethasone/formoterol FEV1 value was significantly higher at a distance of four hours after drug administration (p 0.04) and after the second dose (p 0.02) compared with the group treated with fluticasone/vilanterol. Discussion: Patients in treatment with beclomethasone/formoterol showed improved asthma control and nocturnal symptoms and more stable respiratory function compared with patients receiving fluticasone/vilanterol.

Chemotherapy is one of the main treatment options for cancer. However, chemotherapeutic agents usually suffer from poor pharmaceutical properties that restrict their use. Targeted therapy drugs have been developed to specifically target changes in cancer cells that help these cells to grow. Such drugs often work when standard chemotherapeutic drugs do not, they often have less severe side effects and they are most often used for advanced cancers. The objective of this article is to give an overview about the 16 FDA-approved targeted therapy drugs to treat non-small cell lung cancer.

Background: Diabetes mellitus is a leading cause of illness and death. Pulmonary function test PFT has assumed a key role in epidemiological studies investigating the incidence, natural history and causality of lung disease. Methods: A cross sectional study was conducted in The National Ribat Teaching Hospital and Jabir Abualiz Specialized Diabetes Center in Khartoum state to measure the respiratory muscle power in 31 diabetic patients (case group) and 30 non-diabetics patients (control groups). Pulmonary function tests were measured by using Digital Spirometer-Micro-Plus version. Results: Lung function parameters between diabetic patients and their matched control group show no significant differences between the means of FVC, FEV1 and FEV1/FVC. However, diabetic patients showed significant reduction in PEFR. Conclusions: Exercise and well control of diabetes helped in preserving normal respiratory muscle power. Continuous reasonable exercise with good control is highly recommended for all diabetics.

With the invention of the stethoscope, in the early 1800s, a better diagnosis of heart and lung disorders was opened up. Through the stethoscope's 200-year history, there has been a significant development of the stethoscopy from the use of the simple monaural earpiece to the binaural stethoscope, followed by the electronic stethoscope, which, together with other studies, has enabled a thorough diagnosis of these disorders. Here is a glimpse of this story. The cross-border investigation Far back in time, it has been clear that the function of the heart and lungs played an important role in maintaining life. By tapping with the finger (percussion) and putting the ear to the patient's chest (auscultation), it could hear sound from the body telling about the patient's condition, especially about the presence of fluid or air-filled organs. Auscultation is already described in the Corpus Hippocraticum, in the Diseases II section [1]. The doctor puts the ear to the chest of a patient with water sores, to hear the pain as a wine vinegar from the lungs - or the doctor grabs the patient about the shoulders, shakes him and places his ear to his chest to hear in which side his pleuritis is sitting. Since then, auscultation seems to have been partially forgotten, although it has probably been known by Ambroise Paré and William Harvey [2]. It was not until the late 1700s that it became an important diagnostic aid, just like the pulse clock and the medical thermometer [3 p. 277]. Here, Joseph Leopold Auenbrugger (1722-1809) is considered to be the father of the modern physical examination, which is based on percussion. Percussion he performed by knocking direcly on the thorax with the finger or cupped hands. His discovery of the percussion sounds from the chest during inhaling and exhaling originates from his work in 1760 at the Vienna Military Hospital [4]. In 1761, His little book on thoracic percussion revealing thoracic diseases appeared in 1761 [3p.271], which in 1808 was translated into French by the Parisian physician Jean Nicolas Corvisart des Marets (1755-1821). This contributed to the French doctors starting to use percussion and ausculation more routinely [5]. The limitation of simple auscultation was the fact that the sound was weak and incomplete and therefore there was a need for improved sound quality. In addition, the direct contact with the patient's body could seem insulting

Introduction: Tuberculosis is an infectious disease caused by Mycobacterium tuberculosis (Bacillus of Koch), and presents chronic evolution affecting the lungs frequently. Objectives: Analyse, in the state of Maranhão, the epidemiological prevalence of tuberculosis between 2014 and 2016. Materials and Methods: Documentary and descriptive study of secondary data collected in the database of the dates, epidemiological information and morbidities, between 2014 and 2016. Results: 3,897 cases of tuberculosis in the state of Maranhão were recorded. The most affected age range was 15 to 59 years, totaling 3,111 cases, for both gender; of 60 to 79 years, 577 cases were totaled. Conclusion: Tuberculosis affects more adolescent males from adolescence to old age, and it is necessary to promote knowledge of the disease for the population in order to advance in the control of the same and obtain satisfactory clinical results.

Background: In 2004 we started a phase II trial in non-small lung cancer (NSCLC), stage III, with erlotinib followed by a combination with a platinum-based doublet in unselected patients to identify molecular subgroups benefitting from an EGFR targeting approach. Patients and methods: Induction with erlotinib (E, 150 mg, d1-42) was followed by three cycles of gemcitabine (G, 1250 mg/m², d1+d8, q3w) and cisplatin (P, 80 mg/m², d1, q3w). Patients with at least stable disease after E were treated with a GP + E combination. Induction was followed by surgery and radiation. The trial was conducted as a prospective, multi-center, open label, exploratory phase II study to determine pathological response rate (pRR), as well as secondary endpoints disease free survival (DFS) and overall survival (OS). Results: Of 38 prescreened patients 16 were included in the main study. Due to slow recruitment the study had to be terminated early. Combination of E and GP was well tolerated, surgery was feasible after induction therapy in 12 of 16 patients, 7/12 (58%) patients had a major pathological response (MPR). Median overall survival for patients with MPR was 57.7 months (confidence interval (CI), 37.4 to 78.0; n = 7) and for patients without MPR 11.9 months (CI, 6.4 to 17.4; n = 5). 2/16 patients had an epidermal growth factor receptor (EGFR) mutation. Conclusion: Before discovery of distinct molecular mechanisms in NSCLC our study was an attempt to identify clinical and pathological subgroups that would benefit from E induction. Two patients with an EGFR mutation were identified. MPR was a predictor of long term disease free and overall survival.

Introduction: the perennial pandemic: There are serious challenges posed by the SARS-CoV-2 virus and COVID-19 as the disease. With the persistence of the pandemic over one and half year, it is being feared that the COVID-19 may have become the new reality associated with human existence world over and the mankind may have to live with it for years or even decades. Further, the grievous nature of the disease is evolving further with genomic changes in the virus in form of mutations and evolution of variants, with enhanced infectivity and probably virulence. Acute and chronic phases of COVID-19: Epidemiologically, it is becoming clear that apart from the advanced age and pre-existing conditions, such as diabetes, cardiovascular, pulmonary, and renal diseases, certain constituent factors render some patients more vulnerable to more severe forms of the disease. These factors influence the COVID-19 manifestations, its course, and later the convalescence period as well as the newly defined ‘Long COVID phase. The substantial continuing morbidity after resolution of the infection indicates persisting multisystem effects of ‘Long Covid’. Lung damage associated with COVID-19: COVID-19 is primarily a respiratory disease presenting with a broad spectrum of respiratory tract involvement ranging from mild upper airway affliction to progressive life-threatening viral pneumonia and respiratory failure. It affects the respiratory system in various ways across the spectrum of disease severity, depending on age, immune status, and comorbidities. The symptoms may be mild, such as cough, shortness of breath and fevers, to severe and critical disease, including respiratory failure, shock, cytokine crisis, and multi-organ failure. Implications for the post-COVID care: Depending on the severity of respiratory inflammation and damage, as well as associated comorbidities, duration of injury and genetics, the progressive fibrosis leads to constriction and compression of lung tissues and damage to pulmonary microvasculature. Consequently, the COVID-19 patients with moderate/severe symptoms are likely to have a significant degree of long-term reduction in lung function. Depending on the severity of the disease, extensive and long-lasting damage to the lungs can occur, which may persist after resolution of the infection. Managing the long COVID’s challenges: Given global scale of the pandemic, the healthcare needs for patients with sequelae of COVID-19, especially in those with lung affliction are bound to increase in the near future. The challenge can be tackled by harnessing the existing healthcare infrastructure, development of scalable healthcare models and integration across various disciplines with a combination of pharmacological and non-pharmacological modalities. Following clinical and investigational assessment, the therapeutic strategy should depend on the disease manifestations, extent of damage in lungs and other organs, and associated complications.

Organizing pneumonia (OP), can be seen in association with lung injury, infection, drug intoxication, and connective tissue diseases. Patients of rheumatoid arthritis (RA) are prone to develop interstitial lung disease (ILD), but the pulmonary involvement usually occurs several years after the joint manifestations. Only in about 10% cases of RA, the initial manifestation of the disease can be in the form of interstitial lung disease. OP as the initial manifestation of RA is extremely uncommon occurrence. Here is presented a case of 52-year-old male who presented with OP as the initial manifestation of RA. On investigation, the RA factor and anti-CCP Antibodies were positive. Based on clinical, radiological and histopathological findings the diagnosis was established.

As we know that, Asthma and chronic obstructive pulmonary diseases are well characterized diseases, they can co-exist as asthma-COPD overlap (ACO). The co-existence of asthma-chronic obstructive pulmonary disease overlap (ACO) in chronic obstructive pulmonary disease (COPD) patients is often unrecognized. In patients with a primary diagnosis of COPD or Asthma, the identification of ACO has got implication for better prognosis and treatment. Such patients experience frequent exacerbations, poor quality of life, rapid decline in lung function and high mortality than COPD or Asthma alone. Inhalational steroids provide significant alleviation of symptoms in such patients and some studies suggest that the most severe patients may respond to biological agents indicated for severe asthma. Patients who have asthma with a COPD component tend to present with severe hypoxia because of Irreversible/fixed airway obstruction and impairment of the alveolar diffusion capacity by emphysematous changes. In contrast, patients with COPD who have an asthma component not only have exertional dyspnoea but also develop paroxysmal wheezing or dyspnoea at night or in the early morning. The criteria to diagnose asthma-COPD overlap (ACO) include positive bronchodilator response, sputum eosinophilia or previous diagnosis of asthma, high IgE and/or history of atopy. There is scarcity of literature available in country like India. We highlight the importance of identification of Asthma COPD overlap as different phenotype from COPD or asthma alone as it is challenging to diagnose ACO in India. We report 3 cases having both the features of asthma and COPD, later diagnosed with Asthma-COPD overlap.

Despite the fact, that lung cancer is more common among older smoking men, however it may also develop among young women without a smoking anamnesis. We report here a history of a non-smoking woman, 40 years old, with a diagnosis of lung adenocarcinoma at IV stage. Despite the fact, the woman received three lines of palliative chemotherapy, the disease progressed. After the sample of the tumor was tested by genetic approach, ROS1 mutation was detected, and the patient was treated with a ROS1 inhibitor, Crizotinib. Sharp improvement was observed already after the first week of treatment. After one-month adenocarcinoma shrink, and specific supraclavicular lymph nodes disappeared. Unfortunately, due to problems with financing the treatment was stopped, after what the disease began to progress rapidly, and the patient died after a month due to brain metastasis. This case is noteworthy also because the patient was first diagnosed a thrombophilia with thrombi present in deep calf veins, left heart ventricle and lungs Adenocarcinoma was discovered occasionally when during video-assisted thoracoscopic surgery biopsy specimen was taken from suspicious mass in the lower lobe of the right lung. This story reminds us that lung carcinoma may start with a paraneoplastic syndrome, like thrombophilia as in this case and finding of adenocarcinoma of the lung in young, non-smoking persons is indicative for possible ROS1 gene mutation. In such cases early treatment with ROS1 protein-tyrosine kinase inhibitors should be started as soon as possible.

Pulmonary Alveolar Proteinosis (PAP) is a rare lung disease characterized by excessive accumulation of surfactant lipids and proteins in alveoli and terminal airways. It is caused by impaired GM-CSF signaling [1]. Surfactant is synthesized and secreted by alveolar type II epithelial cells, and removed by uptake and catabolism by these cells, and the alveolar macrophages. Patients with PAP usually describe gradual onset of progressive exertional dyspnea and non-productive cough. However, an asymptomatic presentation is observed in up to 25% of cases, even in the presence of diffuse radiographic changes. Three recognized subtypes exist. Autoimmune PAP is associated with neutralizing GM-CSF autoantibodies and accounts about 90% of cases. Secondary PAP may occur in the context of any disease that reduces the abundance or functionality of alveolar macrophages, resulting in impaired surfactant clearance. Congenital PAP is the result of genetic mutations that disrupt GM-CSF signaling, including mutations in the α- or β-chains of the GM-CSF receptor [1-3].

Introduction: Abdominal hernia is a pathological condition resulting from abnormal protrusion of abdominal viscera. In particular, internal hernias (IH) represents about 0.2-0.9% of all cases with para- duodenal hernias while obturator hernias accounting for only 0.07% of all hernias. Methods: We reported the case report of 79 year old women who was admitted to Internal Medicine Department of our Hospital for lung failure and after few days transferred to our Surgery Department for abdominal pain. Conclusion: Obturator hernia is rare type of hernia and it is more frequent in older women with history of multiple pregnancy, chronic cough, and habitual constipation. In our patients, detailed physical examination and MRI preoperative imaging studies, have induce to the successful diagnosis.

Death due to road traffic accident (RTA) was one of the leading causes of mortality and morbidity in India. In the present cross-sectional study, only the victim using two-wheelers, four-wheelers, and pedestrians were included for comparison to determine the pattern of injuries in these victims of the road traffic accident. There was a predominance of males in all three types of victims of RTA with a peak age of incidence seen in 21-30 years in two-wheeler victims, 41-50 years in four-wheeler victims, and 51-60 years in pedestrian victims. Four-wheeler (HMV/LMV) was the commonest type of offending vehicle involved in all types of victims with collision/ dash as the commonest manner of an accident. Head was the commonest region involved in pedestrian and two-wheeler victims as compared to the thorax in four-wheeler victims of accidents. Abrasion was the commonest surface injury in two-wheeler victims and pedestrians. The laceration was more common in two-wheeler victims as compared to crushed injury in pedestrian victims of road traffic accidents. The brain was the commonest organ involved in two-wheeler and pedestrian as compared to lungs in four-wheeler victims. The liver and spleen were more commonly involved in two-wheeler victims as compared to kidneys and bladder in pedestrian.