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October-December 2018
Volume 12 | Issue 4
Page Nos. 373-488

Online since Wednesday, December 5, 2018

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ORIGINAL ARTICLES - AIRWAY DISEASES  

Impulse oscillometry to differentiate between chronic obstructive pulmonary disease and bronchial asthma p. 373
Mona M Ahmed, Maryam A.A Kader, Esraa M Mohammed
DOI:10.4103/ejb.ejb_86_17  
Background The impulse oscillation system (IOS) yields useful clinical data that predominantly include functional assessment of peripheral airways more than that available from commonly used spirometry. The aim of this study was to differentiate between chronic obstructive pulmonary disease (COPD) and bronchial asthma using IOS. Patients and methods This study was carried out on 40 patients; 20 patients were diagnosed with bronchial asthma and the remaining 20 patients had a clinical diagnosis of COPD. All patients underwent baseline IOS and spirometry, and then after 15 min of inhalation of 400 μg salbutamol, spirometry was repeated in all patients. Results A highly statistically significant difference was found between asthma patients and COPD patients in R20, whereas no statistically significant difference was found between the two studied groups in R5, X5. There was a statistically significant difference between asthma patients and COPD patients in resistance; 75% of asthmatic patients had increased total airway resistance, mainly proximal, 20% had increased total airway resistance, mainly peripheral, and 5% had normal airway resistance, whereas all COPD patients had increased total airway resistance, mainly peripheral. No significant correlation was found between IOS parameters and spirometric parameters in COPD or asthmatic patients, but in both groups, there was a significant correlation between forced expiratory volume 1 (FEV1) and R5, X5. Conclusion IOS provides useful clinical information that prominently includes functional assessment of small, peripheral airway behavior beyond that available from commonly used pulmonary function tests. IOS also aids differentiation between COPD and bronchial asthma. COPD patients had increased airway resistance, mainly in the peripheral airways, whereas asthmatic patients had increased airway resistance, mainly in the proximal airways. R20 is the best IOS parameter to differentiate between these two diseases.
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Role of chest ultrasonography in assessment of diaphragmatic mobility in chronic obstructive pulmonary disease patients on pulmonary rehabilitation program p. 379
Adel M Saeed, Nermine Abd El-Azeim, Ashraf A Gomaa, Yahia R Yousef
DOI:10.4103/ejb.ejb_97_17  
Background Chronic obstructive pulmonary disease (COPD) affects all skeletal muscles including the diaphragm as an extra pulmonary complication. Diaphragmatic mobility improves by pulmonary rehabilitation (PR). Chest ultrasound can be used in assessment of diaphragmatic mobility. Aim Evaluation of chest ultrasound as a simple, noninvasive tool in assessment of diaphragmatic mobility in COPD patients undergoing PR and its correlation with maximal inspiratory pressure (Pi MAX), 6-min walk test (6MWT) and clinical chronic obstructive pulmonary disease questionnaire (CCQ). Patients and methods This study was conducted upon 30 COPD male patients aged 54.50±8.81 years old. All patients were recruited in to a PR program including 16 sessions over 8 weeks. The program included upper limb exercise, lower limb exercise and inspiratory muscle training. Baseline spirometry, Pi MAX, modified medical research council (mMRC) dyspnea scale, CCQ, 6MWT and sonographic assessment of diaphragmatic excursion and thickness were done. Follow-up sonographic evaluation of the diaphragm, CCQ and mMRC every 2 weeks were done. Re-evaluation after the program by the same baseline parameters was done. Results There was statistically significant improvement in diaphragmatic excursion and thickness after PR program as evidenced by chest ultrasound. There was also significant functional improvement evidenced by 6MWT and Pi MAX. Also, there was significant improvement in mMRC and CCQ, but PR did not significantly affect spirometric parameters as forced expiratory volume in first second (FEV1)%, FEV1 value in liter or FEV1/forced vital capacity. Conclusion Chest ultrasound is a beneficial tool in diaphragmatic assessment in COPD patients undergoing PR.
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Serum adiponectin as a biomarker for chronic obstructive pulmonary disease and lung cancer and its relation to severity p. 386
Amany T Gayed, Riham H Raafat
DOI:10.4103/ejb.ejb_22_18  
Introduction ‘Chronic obstructive pulmonary disease’ (COPD) is an inflammatory disorder associated with airway narrowing and airflow limitation in response to air pollution, gases, and smoking and is associated with morbidity and mortality. Cancer is also considered as a systemic inflammatory disorder where pro-inflammatory cytokines and mediators are released. Aim To evaluate serum adiponectin level in COPD and lung cancer and its importance in detecting and predicting severity. Patients and methods A total of 40 patients were recruited in the study: 20 had stable COPD and 20 had lung cancer. Moreover, another 10 age-matched and sex-matched individuals were included as a control group. All were subjected to routine laboratory chest radiography, spirometry, and serum adiponectin level measurement. Results The results showed an increase of adiponectin level in both patients with COPD and those with lung cancer, and significant correlation was found between adiponectin level and forced expiratory volume in 1 s and performance status. Conclusion Adiponectin serum level is elevated in both COPD and lung cancer and significantly elevated in severe cases.
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Assessment of coronary artery diseases in COPD p. 391
Fatmaalzahraa S Abdalrazik, Waleed M El-Sorougi
DOI:10.4103/ejb.ejb_39_18  
Context Chronic obstructive pulmonary disease (COPD) is associated with significant systemic inflammatory response, with downstream adverse clinical effects. This inflammatory response is referred to oxidative stress and inflammatory mediators, which play an important role in the development of atherosclerosis. Preclinical carotid atherosclerosis, characterized by increased intima-media thickness (IMT) on ultrasound imaging, is a surrogate marker for atherosclerosis burden and risk of cardiovascular diseases. Aim To evaluate carotid IMT, in relation to post-forced expiratory volume in 1 s (FEV1) (FEV1 after bronchodilator inhalation) in COPD. Patients and methods A total of 50 patients with COPD were clinically and functionally diagnosed. IMT was measured by B-mode ultrasonography. The correlations between IMT, C-reactive protein (CRP), serum lipids, and post-FEV1 were analyzed. The primary outcome was carotid arteries’ IMT in relation to post-FEV1. Results Cases were divided into three groups according to post-FEV1. In mild COPD severity, mean±SD IMT value was 1.0±0.2, whereas in moderate severity, it was 1.5±0.2, and in severe COPD, IMT was 1.75±0.05 (P<0.001). In mild group, mean±SD value of CRP was 5.2±1.7, in moderate group was 7.5±1.5, and in severe COPD group was 8.4±0.2 (P<0.001). When CRP was correlated with IMT, the correlation was found to be highly significant (P<0.001). In severe airway obstruction group, mean values of serum cholesterol and triglycerides were 239.5 and 189.5, respectively; in moderate group 219.4 and 161.9, respectively; and in mild group 184.2 and 125.6, respectively (P<0.000). Multinomial logistic regression analysis revealed low post-FEV1 as predictor of IMT (P<0.000). Conclusion Carotid duplex should be added to the standard investigations of COPD.
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Study of diaphragmatic mobility by chest ultrasound and echocardiographic changes in chronic obstructive pulmonary disease patients on different modes of mechanical ventilation p. 399
Adel M Saeed, Ghada S Elshahed, Nehad M Osman, Ashraf A Gomaa, Samir M Fahyim
DOI:10.4103/ejb.ejb_52_18  
Objective This study aimed to assess diaphragmatic mobility by chest ultrasonography and echocardiographic changes in mechanically ventilated chronic obstructive pulmonary disease patients on different modes of mechanical ventilation. Patients and methods The present study was carried out on 50 mechanically ventilated chronic obstructive pulmonary disease patients. Chest ultrasonography for the assessment of diaphragmatic mobility in addition to echocardiography was performed on different modes of mechanical ventilation in the same session at any time since mechanical ventilation. Results There was a highly statistically significant relation between diaphragmatic excursion and different modes of mechanical ventilation, where excursion increased significantly, with its peak at pressure-support ventilation (PSV). In terms of diaphragmatic thickness, the thickness of diaphragm decreased significantly at PSV. No significant correlation was detected between echocardiography in Ejection fraction, right ventricular systolic pressure, tricuspid annular plane systolic excursion, and different modes of mechanical ventilation. Conclusion The best diaphragmatic mobility was on PSV, which improved lung volumes and ventilation, and may accelerate the weaning process. In addition, we concluded that the echocardiographic finding was not affected by different modes of mechanical ventilation.
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ORIGINAL ARTICLE: BRONCHOSOCOPY & INTERVENTIONAL PULMONOLOGY Top

Percutaneous tracheostomy, making it easier p. 405
Ahmad Almansoury, Sayed Ali, Hany Said
DOI:10.4103/ejb.ejb_1_18  
Objective Open and percutaneous tracheotomy (PT) lead to many perioperative complications. To minimize the complication and to save time and cost, certain assistive tools can be used like fiberoptic bronchoscope, ultrasound guidance and others. Aim The aim was to compare the three procedures, blind PT, fiberoptic bronchoscopy-guided PT and open tracheostomy, regarding ease of the technique, infection rate, bleeding, and complications of the procedure. Design A retrospective comparative trial was conducted. Setting ICU at Dar El Shefa Hospital and respiratory ICU, Ain Shams University Hospital, were the locations for study conduction. Patients and methods All patients required prolonged mechanical ventilation during period between August 2012 and August 2014. They were assigned into three groups: group I underwent open tracheostomy and included 16 patients, group II underwent blind PT and included 15 patients, and group III underwent fiberoptic-guided PT and included 12 patients. Results A total of 43 patients underwent tracheostomy during the study period. There was a statistically significant difference between the studied groups regarding neck circumference and intubation period before tracheostomy. Regarding hemodynamics, there is no statistically significant difference regarding mean heart rate, mean arterial pressure and FiO2, pH, PaO2, PCaO2, PaO2/FiO2 and oxygen saturation SPO2 before and after each procedure. Regarding complications after procedure, it shows that blind group had higher percentage of patients with no complications (86.7%) followed by fiberoptic group (75%) and open tracheostomy group (50%). It was noticed that the lowest mean of duration of the procedure was found in the blind group (15.7±5.3), followed by fiberoptic group (17.8±3.2) and lastly the open tracheostomy group (25.7±6.3). Conclusion This study showed that PT had fewer complications than open tracheostomy, saved operating room resources as well as was more cost effective.
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Diagnostic yield of fiber optic bronchoscopy in alveolar and/or ground glass opacification in chest computed tomographic scan p. 413
Hoda A.A Youssef, Hany M Khattab, Marwa M Shaban, Sabah A Mohamed, Khaled M Mostafa
DOI:10.4103/ejb.ejb_16_18  
Background and objective Transbronchial lung biopsy (TBLB) can be obtained using forceps and usually represents the centrilobular regions. Therefore, disorders that are centered around terminal and respiratory bronchioles or distributed along the lymphatic routes can be diagnosed. This study investigated the diagnostic yield of flexible bronchoscopy in patients with ground-glass opacity (GGO) or alveolar filling for histopathological diagnosis and found out its complications. Patients and methods Twenty-six patients with predominant GGO or alveolar opacity in the chest computed tomographic (CT) scan were submitted for TBLB for histopathological confirmation. Patients with respiratory failure, heart failure, coagulopathy, or pathognomonic CT patterns were excluded. All patients were subjected to full history taking, chest CT scan, and TBLB with histopathological examination of the specimens. Results The diagnostic yield of TBLB was 73.1%. Histopathological diagnoses included hypersensitivity pneumonitis (23.1%), sarcoidosis (19.2%), adenocarcinoma (11.5%), small cell lung cancer (7.7%), alveolar proteinosis (3.8%), alveolar hemorrhage (3.8%), organizing pneumonia (3.8%), and chronic nonspecific inflammation (26.9%). There was no significant correlation between age, sex, smoking, and histopathological diagnoses. Regarding the predominant CT finding, 15 (57.7%) patients had GGO, whereas 11 (42.3%) patients had alveolar filling with significant (P=0.008) positive correlation between the CT predominant pattern and histopathological diagnoses. There was a positive significant correlation between lymph node enlargement in CT and histopathological diagnosis (P=0.029). Complications from TBLB included the pneumothorax (15.4%) and bleeding (7.7%). Conclusions TBLB seems to be a useful and safe procedure. It is of a high diagnostic value. Therefore, it could be considered a routine diagnostic procedure before thoracoscopic or open lung biopsy.
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Evaluation of the role of video - assisted thoracoscopic surgery in management of empyema p. 419
Mohammed Ali Farrag, Hatem Yazed Al Bawab, Nevine Mohamed Mohamed Abd ELfattah, Eman Badawy Abd ElFattah, Mahmoud Mohsen Mahmoud Khalil
DOI:10.4103/ejb.ejb_23_18  
Background Video-assisted thoracoscopic surgery (VATS) is effective for fibropurulent thoracic empyema and less invasive, and it may be important as a bridge between minimally invasive and conventional open thoracic surgical management. Aim The aim of this study was to determine the optimal treatment of parapneumonic effusion in the fibrinopurulent stage comparing blind thoracostomy versus VATS with regard to efficacy, duration of hospitalization and intercostal tube (ICT) insertion, and need for further surgery or not. Patients and methods This study was a prospective comparative randomized study conducted on 60 patients with confirmed parapneumonic effusion where they were classified into two groups. The blind thoracostomy group: 30 patients underwent blind thoracostomy and the VATS group: 30 patients underwent VATS. Results The incidence of clinical improvement was more in the VATS group when compared to the blind thoracostomy group. The hospital outcome in the VATS group was much better than in the blind group, where in the VATS group, the postoperative length of hospital stay was around 4.8 days and the time of ICT removal was after 5 days from insertion, whereas in the blind group, the length of hospital stay was around 9.7 days and the time of ICT removal was after about 6 days of insertion. The incidence of postoperative complications was higher in the blind group than in the VATS group. Conclusion VATS provides more accurate staging for parapneumonic effusion, an excellent surgical view for a complicated empyema cavity, thus making it possible to perform a sufficient evacuation of all empyema membranes.
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ORIGINAL ARTICLE Top

Safety and diagnostic yield of thoracic ultrasound-assisted transthoracic biopsy performed by a pulmonologist p. 427
Laila Ashour, Eman Ramzy, Mohamed El-Gharib, Rehab Maher, Dalia El-Embaby
DOI:10.4103/ejb.ejb_11_16  
Background Transthoracic ultrasonography (US) is still not utilized to its full potential by respiratory physicians, despite being a well-established and validated imaging modality. It allows for an immediate and mobile assessment that can potentially augment the physical examination of the chest. This work aims to assess safety and diagnostic yield of thoracic US-assisted transthoracic biopsy performed by a pulmonologist. Patients and methods The present study was conducted upon 75 patients who are referred to the Pulmonary Medicine Department, Ain Shams University Hospitals with radiological assessment that reveals pleural-based mass with or without pleural effusion, anterior mediastinal mass, peripheral lung lesions or chest wall lesions. The present study was conducted upon 75 (67 male and 8 female) patients with mean±SD age 58.8±15.64. Results This study showed that 31 cases were presented by peripheral pulmonary mass, 29 pleural lesions, nine mediastinal and six chest wall lesions, 57 of them diagnosed by sonar guided biopsy, 51 of them were malignant and the remaining six were benign. Conclusion Transthoracic US-assisted cutting-needle biopsy is an excellent first-line diagnostic tool for pleural-based lesions of at least 3 cm in diameter. It is a quick, low-cost, safe and well-tolerated tool in the hands of pulmonologists and has a high sensitivity for pleural-based malignancies.
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ORIGINAL ARTICLES - CRITICAL CARE Top

The utility of integrating basic echocardiography in routine respiratory intensive care practice p. 433
Magdy M Khalil, Ghada S El-Shahid, Iman H.E Galal, Ashraf A El-Maraghy, Hanan H.I Mahmoud
DOI:10.4103/ejb.ejb_8_18  
Objective The aim of this study was to evaluate the impact of integrating basic echocardiography in routine assessment of patients admitted to the respiratory intensive care unit and to assess its effect on the outcome of those patients. Patients and methods This prospective cross-sectional study was performed upon 300 patients admitted to the respiratory intensive care unit between January 2015 and December 2015 at Abbasia Chest Hospital. Baseline bedside scanning of patients on admission by portable echo machine for basic echocardiography was reviewed by an experienced cardiologist in all cases as gold standard. Basic echocardiography was done to assess the pericardium, left and right ventricular size and function, valvular lesions, and inferior vena cava. Limited compression ultrasonography was done to detect lower limb deep venous thrombosis (DVT). Results Basic echocardiography showed that 91/300 (30.3%) patients had normal echocardiogram, whereas 209/300 (69.7%) patients had cardiac abnormalities. Basic echocardiography added unsuspected serious conditions to the diagnosis in 33 (11%) patients; five patients with massive pericardial effusion, 22 patients who required inotropics due to dilated cardiomyopathy in 11 patients and ischemic cardiomyopathy in 11 patients, five patients with DVT, and one patient with aortic aneurysm. In addition to this, basic echocardiography confirmed suspected massive pulmonary embolism in seven patients and DVT in 13 patients. Basic echo was able to read the whole finding data as compared to standard echo, with mean sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 93, 97, 97, 98, and 98%, respectively, except for probable incompetent and probable normal tricuspid valve; the standard echo had the upper hand (P<0.0001). Conclusion Basic echocardiography in critically ill patients can readily provide adequate information to get a successful diagnosis and management, especially in life-threatening conditions that can be missed at the primary assessment.
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Impact of integrated use of diagnostic ultrasound examinations in respiratory intensive care units p. 448
Taher A Al Najjar, Ashraf M Madkour, Nehad M Osman, Ashraf A Gomaa, Ahmed M Osman, Mohammed F El Bagalaty, Khaled A Abd EL Kader
DOI:10.4103/ejb.ejb_56_18  
Background Implementing point-of-care multiorgan ultrasound (POCUS) to the initial assessment of ICU patients allows intensivists to immediately integrate ultrasound findings with the patient history, physical, and laboratory results, yielding a powerful clinical synergy, improving diagnostic accuracy, and ameliorating further management plans. The aim of this work was to assess the diagnostic performance and therapeutic effect of POCUS in patients admitted to respiratory ICU (RICU). Patients and methods A prospective study was carried out on patients admitted to the RICU. POCUS examination was performed to the patients within 12 h of admission that included echocardiography, lung ultrasound, abdominal ultrasound including inferior vena cava assessment and lower limb venous duplex. Results A total of 102 patients were included. The total number of sonographic findings was 320, of which 94 (29.3%) were new findings. This resulted in confirmation of the admitting diagnosis, modification of the admitting diagnosis, prompted further testing, change in medical therapy prescribed, and prompted invasive procedures in 35, 51, 11, 41, and 14% of patients, respectively. However, it was ineffective in confirming or modifying diagnosis, provided wrong diagnosis, and missed a diagnosis in 29.4, 2, and 11.7% of patients, respectively. Conclusion Integrating POCUS in the initial assessment of critically ill RICU patients together with standard diagnostic tests lead to diagnostic and therapeutic changes in most of patients which affected the management of these patients. Thus, it seems reasonable to consider the routine use of POCUS as a new respiratory examination option in the armamentarium of the intensivists.
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Effect of inspiratory muscle training on weaning from mechanical ventilation in acute respiratory failure p. 461
Ahmed M Ewis
DOI:10.4103/ejb.ejb_9_18  
Objective This study aimed to evaluate the effect of inspiratory muscle training (IMT) on weaning time and success. Patients and methods This is a prospective, randomized clinical study conducted in an ICU. A total of 15 patients were trained by inspiratory muscle exercise twice per day and 15 patients did not go under training (control group). Training was conducted through tuning the ventilator sensitivity based on the patients’ maximal inspiratory pressure (MIP). The experimental group received IMT starting with an initial load of 30% of their MIP measured immediately after changing patients to pressure support mode of mechanical ventilation (MV) and increased up to 40% as tolerated by the patient. Training was conducted for 5 min, two sessions per day. In addition, these patients received usual care of MV patients. Sputum culture assessment for aerobic organisms was done immediately after intubation. Results This is a prospective randomized control study that collected data on 30 patients with acute respiratory failure. Patients were randomly arranged into two groups (control and experimental). The mean MIP before initiation of weaning in both group was 16 cm H2O. There is a significant difference in the final mean MIP between the experimental group (23.27 cm H2O) and the control group (17.40 cm H2O). There is also significant shortening in the weaning time in the experimental group and less frequent likelihood of reintubation, which was recorded in two cases of control group. Conclusion The IMT during MV may assist in early weaning off MV among patients with acute respiratory failure, and also it improves the weaning success rate, with less frequent likelihood of reintubation.
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ORIGINAL ARTICLES - PULMONARY INFECTIONS Top

Differentiation between pneumocystis jirovecii pneumonia and colonization in immunocompromised patients p. 467
Amal Abd Elazeem Sadon, Mohamed A Saraya
DOI:10.4103/ejb.ejb_105_17  
Background The diagnosis of Pneumocystis jirovecii pneumonia (PJP) is mainly based on microscopic detection of P. jirovecii in the respiratory samples. Quantitative PCR (qPCR) can detect low levels of P. jirovecii DNA but cannot differentiate between infection and colonization. Therefore a new and more accurate assay have to be used. 1,3 BD- glucan (BD-glucan) with a threshold value of 100 pg/ml can differentiate P. jirovecii infection from colonization. Aim The aim of this study is to evaluate the diagnostic accuracy of qPCR and BD-glucan assays in differentiating pneumocystis infection from colonization in immunocompromised patients with help of radiological pulmonary infiltrates. Patients and methods This study consisted of 75 immunocompromised patients (37 renal transplanted patients and 38 HIV patients) who were admitted for radiological pulmonary infiltrates and who presented a clinical picture suspecting PJP. They were investigated using microscopic staining of their respiratory samples (induced sputum or bronchoalveolar lavage).By applying both qPCR and serum BD-glucan assays we can differentiate between P. jirovecii infection from colonization. Results In this study, the first group of 25 patients were diagnosed as definite PJP, the second group of 20 patients were diagnosed as having pneumonia with P. jirovecii colonization, and a third group of 30 patients were diagnosed as having pneumonia without colonization. The number of copies of fungal DNA detected by qPCR were significantly higher in a definite PJP than in those with pneumonia accompanied with P. jirovecii colonization. Also BD-glucan assays were significantly higher in definite PJP by applying a threshold value of 100 pg/ml. The sensitivity and specificity of qPCR for differentiation of PJP infection from colonization were 100 and 64%, respectively, whereas the sensitivity and specificity of BD-glucan were 100 and 96%, respectively. Conclusion Both BD-glucan and qPCR assays had high diagnostic values in differentiating definite PJP from P. jirovecii colonization, and by applying qPCR with two cutoff values combined with serum BD-glucan using a threshold value of 100 pg/ml.
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Detection of tuberculosis in smear predator pulmonary TB in Fayoum Chest Hospital p. 473
Assem F Al Essawy, Randa I Ahmed, Fadwa A.E Raheem, Heba M Bakri
DOI:10.4103/ejb.ejb_119_17  
Background Tuberculosis (TB) is one of the causes of health problem in millions of people annually, and in 2015, it was one of the top 10 reasons of doom worldwide, ranking above HIV/AIDS as one of the important causes of death owing to an intended disease. A negative smear result in pulmonary TB is believed to be a widespread clinical problem, so early detection of smear-negative pulmonary tuberculosis (SNPTB) is important for TB control and restriction of number of deaths, and it is tricky in these patients. Aims To detect TB in SNPTB in Fayoum Chest Hospital Design This was a retrospective study. Setting Fayoum Chest Hospital and Fayoum University Hospital in Egypt were used for conducting the study between 2015 and 2017. Patients and methods Fifty patients suspected to have pulmonary TB and had negative sputum smear results were included in the study. For each patient, full history was taken, and clinical body checkup was done. Then, plain posteroanterior chest radiograph was done. Tuberculin test, direct sputum examination, and other diagnostic methods used for detection such as GeneXpert, bronchoscopy, bronchoalveolar lavage (BAL), transbronchial lung biopsy, Löwenstein–Jensen culture, QuantiFERON, or even open lung biopsy were recorded. Statistical analysis Coding of the data was done then entered with SPSS (Statistical Package for the Social Sciences) version number 18 windows 7 after that data were summarized using mean, standard deviation, median, minimum and maximum in the quantitative data with using frequency (count) & relative frequency (percentage) for categorization of data. Results It was found that 42% of patients were diagnosed by GeneXpert and 46% were diagnosed by BAL during bronchoscopy, whereas 68% of patients had positive ‘Löwenstein–Jensen culture’ result. Conclusion The GeneXpert MTB/RIF assay is an important test for quick diagnosis of acid-fast bacilli SNPTB. Flexible fiberoptic bronchoscopy is a beneficial tool in the diagnosis of pulmonary TB in patients whose sputum smear is negative. Clinical implications are as follows: in patients with SNPTB, microbiological samples should be obtained (through sputum, BAL, or induced sputum), and then radiological investigation should be performed. Thereafter, antituberculous treatment should be started following the diagnosis, with follow-up of the case. Rapid detection and proper treatment of pulmonary TB, even in smear negative patients, can eliminate spread of the infection to others and may decrease the severity of the disease.
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ORIGINAL ARTICLE: MISCELLANEOUS Top

The role of chest ultrasound in detection of pulmonary congestion in hemodialysis patients p. 482
Emad El-Din Abdel-Wahab Koraa, Tamer Mohamed Aly, Hussein Sayed Hussein, Sally Kamil Beshara
DOI:10.4103/ejb.ejb_77_17  
Background Volume overload is a risk factor for mortality in hemodialysis. Pulmonary congestion may be present and mostly asymptomatic between hemodialysis patients, but its outcomes are unknown. Aim The aim of this study was to assess the role of chest ultrasound (US) in detecting pulmonary congestion in hemodialysis patients. Patients and methods This study included 40 patients diagnosed with chronic renal failure on regular hemodialysis. The patients were selected from the Hemodialysis Unit, Dar El Shefa Hospital. Chest US was done predialysis and postdialysis. Results The study was conducted on 40 patients. The age of our patients ranged between 19 and 55 years old; history of hemodialysis ranged between 1 and 8 years; 35% were smokers; 26 (65%) patients were hypertensive; and 17 (42.5%) patients were diabetic. Lung congestion, detected by chest US predialysis, was mild in nine (22.5%) patients, moderate in 17 (42.5%) patients, and severe in 14 (35%) patients. The chest US Kerly’s B-line scores significantly reduced after dialysis, and were normal in seven (17.5%) patients, were mild in 19 (47%) patients, moderate in 12 (30%) patients, and severe in two (5%) patients. Conclusion Chest US can be used as a bedside test for the assessment of lung congestion in hemodialysis patients.
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CASE REPORT Top

Unilateral lung agenesis: a case report and literature review p. 486
Rahul Tyagi, G.S. Chowdhary
DOI:10.4103/ejb.ejb_14_18  
Pulmonary agenesis is an extremely rare malformation of lung with an estimated prevalence of only 34 per million live births. It is even more uncommon in females and on the right side. We report a case of this rare entity.
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