Leaving Bedroom Door Or Window Open May Be Linked To Better Sleep Quality, Study Suggests

By Dr Deepu

A research from Netherlands suggests “leaving a bedroom door or window open may help people sleep better.” Researchers found that “open windows and doors helped reduce carbon dioxide levels and improve ventilation and air flow, which was related to better sleep quality for the healthy young adults in the study.” The findings were published in the journal Indoor Air.
For one night of the study, 17 volunteers slept with an open window or internal door. On another night, the windows and door to the room were kept closed. In the meantime, Mishra and colleagues monitored carbon dioxide levels, temperature, background noise and humidity. The study participants were asked not to drink alcoholic beverages or caffeinated drinks, which could influence sleep. They each slept alone, and the bedroom layout with furniture arrangement was kept consistent.
For measuring sleep quality, participants wore an armband that measures skin temperature, heat flux, bed temperature and skin moisture levels. They also wore a sensor that tracked their movements at night, including indications of restlessness.
Closed environments tended to have less background noise – but they also had significantly higher carbon dioxide levels, which indicated lower ventilation levels.
Open conditions were slightly cooler than closed, although humidity levels were similar across settings, according to the report in the journal Indoor Air.
Notably, carbon dioxide levels were lower when windows or doors were open.
Overall, skin temperature and the bed temperature were higher in closed conditions than open conditions. The number of awakenings and sleep efficiency improved as carbon dioxide levels decreased.
A limitation of the study is that the motion sensor often slipped off the sleepers at night.


Mounier - Kuhn Syndrome

By Dr Deepu







Mounier-Kuhn syndrome is characterized by distinct tracheobronchial dilation that is due to atrophy of the muscular and elastic tissues in the trachea and main bronchial wall. It is more common in men and is typically diagnosed in the 3rd or 4th decades of life. The clinical presentation varies widely, from minimal disease in which lung function is preserved to severe respiratory failure and death. Involvement occurs at different levels, from the trachea down to the 4th bronchial branch.Although its cause is not fully known, tracheobronchomegaly is reportedly linked to familial susceptibility and is perhaps inherited through an autosomal recessive mechanism. Cases are often sporadic.

Mounier-Kuhn syndrome has 3 subtypes. In type 1, there is a slight symmetric dilation in the trachea and main bronchi. In type 2, the dilation and diverticula are distinct. In type 3, diverticular and saccular structures extend to the distal bronchi. The main problems associated with this disease are ineffective cough consequent to pathologic dilation in the tracheobronchial tree and the impairment of mucociliary activity. These cause difficulty in expectorating secretions and lead to recurrent LRTIs.The symptoms of Mounier-Kuhn syndrome are nonspecific. In the absence of infection, the disease can develop asymptomatically. Bronchiectasis and LRTIs are clinically prominent, and recurrent pneumonia and fibrosis can develop.

Diagnosis is often made by using CT, through which abnormally large air passages are detected. In adults, the diagnostic criteria are diameters of the trachea, >30 mm; of the right main bronchus, 20 mm; and of the left main bronchus, 18 mm.Upon pulmonary function testing, decreased bronchial flow speed, increased tidal volume, and dead spaces may be observed. Bronchoscopy can detect the pathologic processes that affect the tracheobronchial structures—specifically, dilation in the trachea and main bronchi during inspiration, and constriction and even collapse during expiration and coughing.

Connective-tissue diseases, ataxia-telangiectasia, ankylosing spondylitis, Ehlers-Danlos syndrome, Marfan syndrome, Kenny-Caffey syndrome, Brachmann-de Lange syndrome, and cutis laxa (elastolysis) are also associated with secondary tracheobronchial enlargement.All of these conditions should be considered in the differential diagnosis.

Asymptomatic patients require no specific treatment. Cessation of smoking is highly beneficial, as is minimizing exposure to industrial and occupational irritants and pollutants. In symptomatic patients, therapy is supportive but is limited to respiratory physiotherapy for clearing secretions and to antibiotic use during infectious exacerbations.Although tracheal stenting has been helpful in severe cases, surgery is rarely performed because of the diffuse nature of the disease. Lung transplantation provided no proved benefit in regard to the risk of morbidity and death.

Schwartz M, Rossoff L. Tracheobronchomegaly. Chest 1994; 106(5):1589–90. [PubMed]

Mounier-Kuhn P. Dilatation de la trachee: constatations radiographiques et bronchoscopiques. Lyon Med 1932;150:106–9.

 Damgaci L, Durmus S, Pasaoglu E. Mounier-Kuhn syndrome (tracheobronchomegaly). Tanisal ve Girisimsel Radyoloji 2002;8(1):165–6.

Dunne MG, Reiner B. CT features of tracheobronchomegaly. J Comput Assist Tomogr 1988;12(3):388–91.[PubMed]

Noori F, Abduljawad S, Suffin DM, Riar S, Pi J, Bennett-Venner A, et al. Mounier-Kuhn syndrome: a case report. Lung 2010;188(4):353–4.[PubMed]

Menon B, Aggarwal B, Iqbal A. Mounier-Kuhn syndrome: report of 8 cases of tracheobronchomegaly with associated complications. South Med J 2008;101(1):83–7. [PubMed]

Ghanei M, Peyman M, Aslani J, Zamel N. Mounier-Kuhn syndrome: a rare cause of severe bronchial dilatation with normal pulmonary function test: a case report. Respir Med 2007; 101(8):1836–9. [PubMed]



Noninvasive ventilation may be beneficial for patients with acute hypercapnic respiratory failure during COPD exacerbations, data indicate

By Dr Deepu


A review of a recent meta-analysis published in the Annals of Emergency Medicine indicates that noninvasive ventilation provides benefit in patients with acute hypercapnic respiratory failure during chronic obstructive pulmonary disease (COPD) exacerbations, reducing mortality and the need for mechanical ventilation.

Authors also added that noninvasive ventilation also may improve length of hospital stay, serum pH, and oxygen partial pressure. The meta-analysis included 17 randomized controlled trials with 1264 patients.
The review authors noted that severe COPD is characterized by hyperinflation, airway obstruction, and decreased respiratory muscle function. In this setting, exacerbation can result in hypercarbic respiratory failure. Usual care includes controlled oxygenation, bronchodilators, corticosteroids, and antibiotics. If these interventions fail, intubation is initiated.

Limitations of the meta-analysis include the variability of usual care and noninvasive ventilation duration in the studies, the potential for publication bias regarding the need for intubation, and low heterogeneity for both mortality and the need for intubation.

The meta-analysis provides strong evidence that noninvasive ventilation reduces mortality, the need for intubation, and hospital length of stay in patients with acute hypercapnic respiratory failure during an acute exacerbation of COPD. The findings support a trial of noninvasive ventilation in patients with a pH of less than 7.30 before proceeding with intubation.

Sputum eosinophil count may predict severity of COPD in smokers, research suggests

- Blood eosinophil count alone not predictive in SPIROMICS cohort
By Dr Deepu

Investigators found that “sputum eosinophil count proved to be a better biomarker of chronic obstructive pulmonary disease (COPD) severity and exacerbations than blood eosinophil count alone in a study involving a large group of smokers with a broad range of airflow obstruction severities.” The investigators found, “in the analysis...blood eosinophil count as a single biomarker was not predictive of sputum eosinophils and was not associated with disease severity or exacerbations unless combined with sputum count.” But, “increased sputum eosinophil inflammation...was found to be associated with more severe COPD, decreased lung function, worse emphysema and air trapping, and a greater likelihood of exacerbations.” The findings were published in The Lancet Respiratory Medicine
Patients enrolled in SPIROMICS had a smoking history of at least 20 pack-years and were recruited from six clinical sites and subsites in the U.S. between November 2010 and spring 2015. All had complete baseline blood cell counts, and a subset had acceptable sputum counts.

A total of 2,499 participants with available blood counts were stratified by mean blood eosinophil count: 1,262 patients with low (<200 cells per μL) and 1,237 with high (≥200 cells per μL) blood eosinophil counts.

A total of 827 patients were eligible for stratification by mean sputum eosinophil percentage including 656 with low (<1.25%) and 171 with high (≥1.25%) sputum eosinophil percentages. Analyses were also conducted involving blood eosinophil cutoffs of 300 cells/μL and sputum eosinophil cutoffs of 2%.

The high sputum eosinophil group had significantly lower median forced expiratory volume in 1 second (FEV)1 percentage predicted than the low sputum eosinophil group, both before (65.7% [IQR 51.8-81.3] versus 75.7% [59.3-90.2], P<0·0001) and after (77.3% [63.1-88·5] versus 82.9% [67.8-95.9], P=0.001) bronchodilation.

Qualitative computed tomography (CT) density measures for emphysema and air trapping were significantly higher in the high sputum eosinophil group than in the low sputum eosinophil group and exacerbations requiring corticosteroids treatment were more common in the high versus low sputum eosinophil group (P=0.002).
The main findings of the study are:

FEV1 percentage predicted was significantly different between low and high blood eosinophil groups, but differences were less than those observed between the sputum groups

The high blood eosinophil group had slightly increased airway wall thickness (0.02 mm difference, P=0·032), higher St George Respiratory Questionnaire symptom scores (P=0.037), and increased wheezing (P=0.018, but no evidence of an association with COPD exacerbations (P=0.35) or the other indices of COPD severity, such as emphysema measured by CT density, COPD assessment test scores, BMI, airflow Obstruction, Dyspnea, and Exercise index, or Global Initiative for Chronic Obstructive Lung Disease stage

Blood eosinophil counts showed a weak but significant association with sputum eosinophil counts (receiver operating characteristic area under the curve of 0.64, P<0.0001), but with a high false-discovery rate of 72%

With the higher blood eosinophil cutoff of 300 cells/μL, no significant differences were seen between the high and low count groups. But at the higher 2% sputum eosinophil cutoff, significant differences were seen between the low and high groups for all categories of COPD exacerbations.



The ECLIPSE study reported that 1,483 patients stratified by blood eosinophil counts did not have different numbers of COPD exacerbations in the previous year. Researchers noted that higher blood eosinophils are not associated with COPD exacerbations except when combined with increased sputum eosinophils or with other characteristics, such as a previous history of exacerbations. In the SPIROMICS cohort, higher sputum eosinophil counts alone are associated with exacerbations even in mild to moderate COPD

Survival Rates Have Improved Among Patients With Early Stage NSCLC, Research Indicates

By Dr Deepu
Finally a ray of hope for lung cancer patients, in a finding, researchers report that survival rates have improved among those with early stage disease.
The study included more than 65,000 people diagnosed with stage 1 non-small-cell lung cancer between 2000 and 2010. In that group, 62 percent had surgery, 15 percent received radiation therapy, 3 percent had both surgery and radiation and 18 percent received neither treatment.

The two-year survival rate for people treated with either surgery or radiation therapy rose from 61 percent in 2000 to 70 percent in 2009 -- corresponding to a 3.5 percent annual decrease in death from lung cancer.
Author also noted that while the proportion of patients who did not receive treatment fell from about 20 percent in 2000 to just under 16 percent in 2010, too many still do not receive treatment for "an otherwise highly curable disease."

E-Cigarettes May Cause Unique Harm To Innate Lung Immunity, Research Suggests

By Dr Deepu

Research indicates “e-cigarettes cause unique harm to innate lung immunity, challenging the concept that they are a healthier alternative to traditional cigarettes.” The findings were published in the American Journal of Respiratory Critical Care Medicine.
Researchers collected induced sputum samples from 15 current e-cigarette users, 14 current cigarette smokers, and 15 never-smokers. They analyzed the samples using quantitative proteomics, as well as total and individual mucin concentrations. Neutrophil extracellular trap (NET) formation was also analyzed and compared among the groups.

The researchers found that both cigarette smokers and e-cigarette users had a significant increase in oxidative stress-related proteins, such as thioredoxin (TXN), compared with nonsmokers (P ≤ 0.05 for all levels). These proteins are markers of activation of the innate defense mechanisms associated with lung disease, the researchers explain.

Compared with cigarette smokers and nonsmokers, e-cigarette users had higher levels of neutrophil granulocyte- and NET-related proteins, including matrix metalloproteinase-9 (MMP-9), a major contributor to chronic lung disease (P ≤ 0.05 for all levels). These elevations were seen despite no increase in the sputum neutrophil cell counts.

Total mucin concentrations were highest in the sputum of smokers and were similar among e-cigarette users and nonsmokers. But, mucin composition, which has been correlated to progression of lung disease in previous studies, was similar between smokers and e-cigarette users.
The elevated levels of markers known to be associated with cigarette smoke and lung disease/inflammation, such as TXN and MMP-9, in the sputum of both cigarette smokers and e-cigarette users, indicates commonality in the impacts of these products on airway physiology, such as increased oxidative stress and activation of innate defense mechanisms.
12 of the 15 e-cigarette users smoked cigarettes in the past, and 5 said they occasionally still smoked cigarettes.
Authors wrote "In conclusion, our results challenge the concept that e-cigarettes are a healthier alternative to cigarettes and reverse smoking-induced adverse health effects,".



Emergency funding needed to combat climate change -WMA

By Dr Deepu

 (WMA News Release, October 20, 2017).
A call for national governments to provide designated funds for the strengthening of health systems to combat climate change has come from the World Medical Association. In a policy statement adopted at its annual Assembly in Chicago, the WMA emphasises the urgency for taking action and for emergency planning on local, national and international levels.
WMA President Dr Yoshitake Yokokura said: ‘With the next United Nations conference on climate change less than a month away, it is important that the voice of the world’s physicians is heard about the risks posed to health by climate change’. 
The WMA says that human influence on the climate system is clear, with recent emissions of green-house gases the highest in history. Recent climate changes have had widespread impact on human and natural systems. Compelling evidence proves numerous health risks which threaten all countries. These include more frequent and potentially more severe heatwaves, droughts, floods, storms and bushfires. 

Climate change, especially warming, is already leading to changes in the environment in which disease paths flourish. There is reduced availability and quality of potable water, and worsening food insecurity leading to malnutrition and population displacement. And although climate change is universal, its effects are uneven, with many of the areas most affected the least able to manage the challenges it poses. Those with generally the poorest health and lowest life and health expectancy will be least able to adapt to the adverse effects of climate. 


Dr Yokokura said: ‘We are also urging national governments to provide for the health and wellbeing of people displaced by environmental causes, including those becoming refugees because of the consequences of climate change’

BOOP

By Dr Deepu sourced from Chest Council of India
BOOP

Terminology

Organising pneumonia (OP) is a histologic pattern of alveolar inflammation with varied aetiology (including pulmonary infection). The idiopathic form of OP is called cryptogenic organising pneumonia (COP) and it belongs toidiopathic interstitial pneumonias (IIP's).

COP was previously termed bronchiolitis obliterans organising pneumonia (BOOP), not to be confused with bronchiolitis obliterans per se.
Epidemiology

The presentation is commonest in the 55-60 age group.
Clinical presentation

Patients present with a short history (i.e. less than ~2 months) of breathlessness, non-productive cough, weight loss, malaise and fever. There is no association with smoking.
Pathology

In addition to the alveolar inflammatory changes found with regular pneumonia, there is also the involvement of the bronchioles.

Histologically, it is characterised by mild chronic patchy interstitial inflammation without fibrosis and the presence of buds of granulation tissue made of mononuclear cells, foamy macrophages, and fibrous tissue (Masson bodies) in the distal airspaces which may cause secondary bronchiolar occlusion due to extension of the inflammatory process. Hence, the reason for being previously termed bronchiolitis obliterans organising pneumonia (BOOP).
Radiographic features

Plain radiograph
consolidation unilateral or bilateral patchy areas (commonest finding ): often migratory can affect all lung zones usually peripheral, subpleural, peribronchovascular nodules foci of granulation tissue up to 1 cmmay mimic neoplasm if >5 cm in sizemay be numerous in immunocompromised patients

CT

The most common HRCT features include:

patchy consolidation with a predominantly subpleural and/or peribronchial distribution small, ill-defined peribronchial or peribronchiolar nodules large nodules or masses bronchial wall thickening or dilatation in the abnormal lung regions perilobular pattern with ill-defined linear opacities that are thicker than the thickened interlobular septa and have an arcade or polygonal appearanceground glass opacity or crazy paving

The reverse halo sign (atoll sign) is considered to be highly specific, although only seen in ~20% of patients with COP
History and etymology

It was first described by Davison and colleagues in 1983.
Differential diagnosis

On radiograph consider:

differential for peripheral consolidation:
reverse bat wing opacitiesdifferential for bilateral airspace opacities

On CT consider:

adenocarcinoma in situ or minimally invasive (formerly bronchoalveolar carcinoma)pulmonary lymphoma
pulmonary vasculitis/vasculitides
sarcoidosis chronic eosinophilic pneumonia (for a subpleural consolidative pattern)

Patients With COPD Who Live Alone May Be Less Active, Research Suggests

By Dr Deepu

A recent research suggests “patients with chronic obstructive pulmonary disease (COPD) who live with a spouse, partner, or other caregiver are more active than patients who live alone, and are also more likely to participate in pulmonary rehabilitation programs.” The findings are to be published online in Annals of the American Thoracic Society.
Patients with partners are associated with an 11-fold higher likelihood of participation in a pulmonary rehabilitation program, according to the retrospective analysis of data from the CASCADE (COPD Activity: Serotonin Transporter, Cytokines and Depression) study of depression and functioning among COPD patients, to be published online in Annals of the American Thoracic Society.
The analysis included 282 CASCADE study participants with moderate to severe (GOLD Stage II-IV) COPD (age: 68 ± 9; FEV1% predicted: 45 ± 16) recruited from two Veterans Administration hospitals and two academic medical centers. Eighty percent of the patients were white men, 90% reported having a family caregiver, and 75% lived with others (family members or friends).
Physical activity was measured with a validated accelerometer at baseline, and at 1 and 2 years. Additional self-care behaviors assessed included pulmonary rehabilitation attendance, smoking status, receipt of influenza and/or pneumococcal vaccinations, and medication adherence.
Structural social support indicators included living status, being partnered, the number of close friends/relatives, and the presence of a family caregiver.
Functional social support was measured with the Medical Outcomes Social Support Survey (MOSSS), and mixed-effects and logistic regression models were also used.
Among the main findings:

Participants who lived with others took 903 more steps per day than those who lived alone (95% CI, 373-1433; P=0.001)
Increases in the MOSSS total score were associated with more steps per day (β=10, 95% CI, 2-18; P=0.02)
The odds of pulmonary rehabilitation participation were more than 11 times higher if a patient had a spouse or partner caregiver compared with not having a caregiver (OR=11.03, 95% CI, 1.93-62.97; P<0.01)
Higher functional social support (MOSSS total score) was associated with marginally lower odds of smoking (OR=0.99, 95% CI, 0.98-1.00; P=0.03) and higher odds of pneumococcal vaccination (OR=1.02, 95% CI,m 1.00-1.03; P=0.02)
No significant relationships were seen between social support and influenza vaccination or adherence with inhaler or nebulizer medications.

FDA approves biosimilar version of bevacizumab

By Dr Deepu


FDA  has approved a “biosimilar version of” Avastin (bevacizumab). “Like the reference product, the biosimilar bevacizumab is approved for use in several types of cancer, including metastatic colorectal cancer, non-small cell lung cancer (NSCLC), renal cell carcinoma, cervical cancer, and glioblastoma.” “Like Avastin, the labeling for” the new product, has a boxed warning about an increased risk of: holes in the stomach and intestines; surgery and wound healing complications; and severe or fatal pulmonary, gastrointestinal, central nervous system and vaginal bleeding.”

Behavioral Interventions Help Prevent Anxiety Disorders (JAMA Psychiatry)

By Dr Deepu

Meta-analysis finds small, but significant benefit to these programs
Psychological and/or educational interventions showed a modest benefit for preventing anxiety disorders, a systematic review and meta-analysis found.Researchers  published the data  JAMA Psychiatry. The researchers examined 29 randomized controlled trials comprising over 10,000 patients from 11 countries, and found a small, but significant benefit from psychological and/or educational interventions on anxiety prevention compared to usual care. Most trials examined the benefit of cognitive behavioral therapy, either individualized or through a computerized self-help format. Other examined interventions included psycho-educational, acceptance and commitment therapy and psychosocial interventions.
The significance of the study is this being the first meta-analysis to examine the effectiveness of these methods in anxiety prevention, the authors quoted, and suggested that implementing prevention programs that target a large population could have significant benefit.
I feel this could have a significant contribution in management of stress and anxiety in COPD, which is an ignored entity as of now. Treating these problems will have a positive impact on patients life and he can cope up with his problems with ease.

Poor Sleep May Be Associated With An Increased Risk For Alzheimer’s, Small Study Suggests

By Dr Deepu

“Poor sleep may be an indication of increased risk for Alzheimer’s disease,” researchers found after studying “101 cognitively normal people, average age 63.” All participants had their “spinal fluid for the presence of indicators of the plaques and tangles that are characteristic of Alzheimer’s.” After controlling for confounding factors, the study authors found that “poor sleep quality, sleep problems and daytime sleepiness were associated with increased spinal fluid indicators of Alzheimer’s disease.”
The highlights of the study
They Investigated the relationship between sleep quality and CSF AD biomarkers in a cohort enriched for parental history of sporadic AD, the Wisconsin Registry for Alzheimer's Prevention.
101 participants (mean age 62.9 ± 6.2 years, 65.3% female) completed sleep assessments and CSF collection and were cognitively normal.
Sleep quality was measured with the Medical Outcomes Study Sleep Scale. CSF was assayed for biomarkers of amyloid metabolism and plaques (β-amyloid 42 [Aβ42]), tau pathology (phosphorylated tau [p-tau] 181), neuronal/axonal degeneration (total tau [t-tau], neurofilament light [NFL]), neuroinflammation/astroglial activation (monocyte chemoattractant protein–1 [MCP-1], chitinase-3-like protein 1 [YKL-40]), and synaptic dysfunction/degeneration (neurogranin).
Relationships among sleep scores and CSF biomarkers were assessed with multiple regression, controlling for age, sex, time between sleep and CSF measurements, and CSF assay batch.
Results: Worse subjective sleep quality, more sleep problems, and daytime somnolence were associated with greater AD pathology, indicated by lower CSF Aβ42/Aβ40 and higher t-tau/Aβ42, p-tau/Aβ42, MCP-1/Aβ42, and YKL-40/Aβ42.
No significant associations between sleep and NFL or neurogranin.
Conclusions: Self-report of poor sleep was associated with greater AD-related pathology in cognitively healthy adults at risk for AD. Effective strategies exist for improving sleep; therefore sleep health may be a tractable target for early intervention to attenuate AD pathogenesis.


The findings were published online July 5 in Neurology. 

Sleep Apnea May Increase Risk Of Patients With Type 2 Diabetes Developing Advanced Retinopathy, Study Suggests

By Dr Deepu

A study has revealed that patients with sleep apnea who also have type 2 diabetes “have more than double the risk of worsening retina disease compared to diabetics without the sleep breathing disorder,”. The study was published in the American Journal of Respiratory and Critical Care Medicine. Researchers found that 43% of the study participants who had type 2 diabetes and sleep apnea had diabetic retinopathy, compared to 24% of participants who had type 2 diabetes without sleep apnea.

Are WHO approved nucleic acid amplification tests causing large-scale "false identification" of rifampicin-resistant tuberculosis?

By Dr Deepu
The nucleic acid amplification tests (NAATs): Line probe assay and GeneXpert (Xpert) have evolved as the primary tool for identification of rifampicin (RIF)-resistant (RR) tuberculosis (TB) worldwide, primarily because of the ease and speed. They rechecked RR isolates identified by NAATs from presumptive RR TB cases belonging to South India by the Revised National TB Control Program, India using multiple RIF concentrations on Bactec MGIT system and compared the mutation patterns with the resistance levels.
Researchers state that they used standard protocol for Bactec MGIT system as given by the manufacturer modified for the multiple RIF concentrations. All the retests were done in a certified BSL3 laboratory.
Astonishingly they found that there is a mismatch of up to 20% (RIF breakpoint 0.5 mg/L); the NAATs probably overidentifying RR TB. Half of the cases with mismatch showed a sub-breakpoint rise in resistance level (0.125 mg/L to 0.5 mg/L RIF).
They finally concluded by stating probable reasons for the mismatch are "sub-breakpoint low-level resistance mutants," hetero-resistant bacterial populations, and other inherent test limitations along with the low RR TB prevalence in South India (<5%) among "presumptive multidrug-resistants." They also quoted, could be due to the incomplete selection pressure by an inadequate RIF exposure caused by various factors including a low-RIF dosage being used widely and poor Directly observed treatment.
They concluded"To prevent the false diagnosis of RR TB in a massive scale when using NAATs, we may need to enforce a carefully targeted testing approach and a phenotypic susceptibility testing with multiple RIF concentrations for confirmatory purposes".
Find the full text article here

Diaphragm Palsy

By Dr Deepu, image and video Courtesy Dr Rajesh
A 61 yr old male, never smoker, no lung issues, developed GBS  (guillian barre).   Post IvIG therapy he was recovering well.   Then the consulting neurologist noticed that he is in respiratory distress. Below is his cxr and video showing his breathing pattern.



Diaphragmatic paralysis can be unilateral or bilateral.

Clinical presentation

Clinical features are highly variable according to underlying aetiological factor

unilateral paralysis: asymptomatic in most of the patients as the other lung compensates.may have dyspnea, headaches, fatigue, insomnia and overall breathing difficultybilateral diaphragmatic palsy can be a medical emergency; they present with severe dyspnea, even with mild exertion


Radiographic featuresPlain radiograph

Normally the right dome of the diaphragm is higher in position as compared to the left dome, if the left dome of the diaphragm is elevated (>2 cm) diaphragmatic palsy should be suspected.

Fluoroscopy

Fluoroscopic examination of the diaphragm ("sniff test") very useful in diagnosing a diaphragmatic paralysis. In normal individuals, both hemidiaphragm will descend with inspiration. In cases of unilateral diaphragmatic paralysis, the affected side demonstrates a paradoxical upward movement.

Ultrasonography

An alternative to fluoroscopy in diagnosing this condition, particularly useful in the paediatric population. Real-time ultrasound is ideal for evaluation of spontaneous respiratory diaphragmatic motion (may require temporary disconnection of the ventilator). This can be performed in the axial plane to compare the two hemidiaphragm simultaneously. Additional coronal or sagittal M-mode can help quantify the degree of movement of each individual hemidiaphragm. Diagnostic criteria include paradoxical movement, excursion of less than 4 mm, and a difference > 50% between the excursion of one hemidiaphragm compared to the other.

Treatment and prognosis

Patients with unilateral diaphragmatic paralysis do not require treatment. There may be an option for phrenic nerve stimulation in some cases.

Pioneers in pulmonology Gustav Kilian

By Dr Deepu



Gustav Killian (June 2, 1860 – February 24, 1921) was a German laryngologist and founder of the bronchoscopy.
He was also born in Mainz, and educated at the University of Freiburg-im-Breisgau. He made revolutionary advances in the diagnosis and treatment of affections of the infralaryngeal passages, especially in the diagnosis and removal of foreign bodies in the bronchial tubes, by means of his new art of bronchoscopic control. His first college appointment was as assistants to Professor Hack of the chair of otolaryngology in Mainz. The sudden death of Wilhelm Hack (1851–1887) led to his succession by Killian, although he was not made professor at the time. His revolutionary activity on bronchoscopy gained him an appointment as professor of laryngology in the University of Berlin; this was the first professorship of such scope in Germany. Killian introduced another innovation known as suspension laryngoscopy into the technic of his specialty. 

FDA approved betrixaban for the prophylaxis of venous thromboembolism (VTE) in adult patients

By Dr Deepu


On June 23, 2017, the U.S. Food and Drug Administration approved betrixaban for the prophylaxis of venous thromboembolism (VTE) in adult patients hospitalized for an acute medical illness who are at risk for thromboembolic complications due to moderate or severe restricted mobility and other risk factors for VTE.
Approval was based on data from APEX (NCT01583218), a randomized, double-blind, multinational clinical trial comparing extended duration betrixaban (35 to 42 days) to short duration of enoxaparin (6 to 14 days) in the prevention of VTE in an acutely medically ill hospitalized population with risk factors for VTE. The trial randomized 7,513 patients to either betrixaban or enoxaparin treatment. Patients on the betrixaban arm took an initial dose of 160 mg orally on day 1, then took 80 mg once daily for 35 to 42 days and received a placebo injection once daily for 6 to 14 days. Patients on the enoxaparin arm received 40 mg subcutaneously once daily for 6 to 14 days and took a placebo pill orally once daily for 35 to 42 days.
Efficacy was measured in 7,441 patients by a composite outcome score comprised of either the occurrence of asymptomatic or symptomatic proximal deep vein thrombosis, non-fatal pulmonary embolism, or VTE-related death. Fewer events were observed in patients receiving betrixaban (4.4%) compared with those taking enoxaparin (6%) (relative risk 0.75, 95% CI: 0.61, 0.91).
The most common adverse reactions (≥5%) with betrixaban were related to bleeding. Overall, 54% of patients receiving betrixaban experienced at least one adverse reaction compared with 52% taking enoxaparin. The frequency of patients reporting serious adverse reactions was similar between betrixaban (18%) and enoxaparin (17%). The most frequent reason for treatment discontinuation was bleeding, with an incidence rate for all bleeding episodes of 2.4% and 1.2% for betrixaban and enoxaparin, respectively. The incidence rate for major bleeding episodes was 0.67% and 0.57% for betrixaban and enoxaparin, respectively.

The recommended dose of betrixaban is an initial single dose of 160 mg starting on day 1, followed by 80 mg once daily taken for 35 to 42 days at the same time each day with food.
Get prescribing information here 

Study Shows Obesity Rate Exceeds 10 Percent Worldwide

By Dr Deepu

 Researchers say the global obesity problem now affects one in ten people in the world. An estimated 603 million adults are obese, including 107 million children.

        Excess weight accounted for four million deaths worldwide, 70 percent from cardiovascular disease, and it turns out, almost 40 percent of those deaths were in people who were overweight, not obese, the study found.
        The findings were published in a study in the New England Journal of Medicine. Researchers found that obesity rates at least doubled in 73 countries between 1980 and 2015 and continuously increased in most other countries. The researchers analyzed some 1,800 data sets from around the world, and found that excess weight played a role in four million deaths in 2015, from heart disease, diabetes, kidney disease and other factors.

        About 30% of the world’s population is affected by weight problems. Individuals were classified as overweight if their body mass index was in the 25 to 29 range, while obesity is defined as anyone with a BMI of 30 or more.
 US has the highest rate of obesity among children and young adults at almost 13%, while Egypt has the highest adult obesity rate at 35%, according to the same study

WHO swaps H1N1 for 2017-18 flu vaccine, recommends 2 new H7N9 viruses

By Dr Deepu


The World Health Organization's (WHO's) flu vaccine advisory group today recommended changing one strain—the 2009 H1N1 component—for the Northern Hemisphere's 2017-18 flu season, which mirrors a recommendation it made last September for the Southern Hemisphere's upcoming season.

Also, the advisors reviewed the latest genetic information about recent avian and other zoonotic flu viruses and recommended two new candidate vaccine viruses for H7N9 avian flu, plus three new ones for other potential pandemic threats.

Seasonal flu change

The new H1N1 vaccine strain, called A/Michigan/45/2015, replaces A/California/7/2009, which has been in use as a vaccine strain since the 2009 H1N1 virus became a regularly circulating seasonal flu strain after the 2009-10 pandemic. WHO advisors recommended it for the Southern Hemisphere's 2017 vaccine to improve protection against subclades that emerged last year.

Since September 2016, 2009 H1N1 has circulated at very low levels in most parts of the world, with most viruses belonging to subclade 6B.1, with a small portion of them in Asia and Oceana part of subclade 6B.2.

Though tests on ferret sera showed that most recent circulating viruses were antigenically similar to both the California and Michigan vaccine strains, tests using human sera hinted at a possible gap in protection from the California strain among the adult samples.

The WHO recommends the following for the Northern Hemisphere's trivalent vaccines:

For H1N1, an A/Michigan/45/2015-like virusFor H3N2, an A/Hong Hong/4801/2014-like virusFor B, Brisbane/60/2008-like virus (belonging to the Victoria lineage)

For quadrivalent versions that contain two influenza B strains, the WHO experts recommended adding Phuket/3073/2013-like virus, a Yamagata lineage virus that is the second B component of quadrivalent vaccines for both the Southern Hemisphere's past and the Northern Hemisphere's current season.

H3N2 has been the dominant strain globally over the past several months, and the WHO said circulating viruses within the 3C2.a clade have become genetically diverse but remain antigenically similar to the current vaccine strain.

Five new pandemic candidate vaccine viruses

As vaccine advisors assess the need for new seasonal flu vaccine strains, they also look at the latest zoonotic influenza strains to see if any new candidate vaccine viruses are needed to assist with pandemic preparedness.

At a media telebriefing yesterday to address China's recent surge of H7N9 activity and recent genetic changes, officials said the virus has diverged into two distinct genetic groups, which would likely have implications for candidate vaccine viruses.

Today the group said that recent H7N9 viruses fall into the Yangtze River Delta (YRD) or Pearl River Delta (PRD) hemagglutinin lineages, and that two existing candidate vaccine viruses don't seem to protect against recent YRD-lineage viruses. They proposed a new candidate vaccine virus to protect against those viruses.

Also, they said the newly identified highly pathogenic H7N9 viruses isolated from poultry and people are genetically and antigenically distinct from other H7N9 viruses, including recommended candidate strain, including the newly proposed one. Therefore, the group recommended a new candidate vaccine virus to protect against the highly pathogenic H7N9 strain.

The group also recommended three other candidate pandemic vaccine viruses, two against recent variant H1N1 strains and one against the recent H5N6 virus circulating in Japan and South Korea.
Another option would be to see of some H7N9 viruses cross-protect against both lineages.

Septic Pulmonary Embolism

By Dr Deepu
Septic Pulmonary Emboli.
GOLDEN POINT: The most common sources of septic pulmonary emboli are infected venous catheters, including pacemaker wires, tricuspid valve endocarditis, septic thrombophlebitis and indwelling prosthetic devices. The diagnosis is usually established by positive blood cultures and the presence of an infected source for the emboli.
Watch the HRCT video showing septic emboli.

GOLDEN PEARL: The usual radiographs and CT scan demonstrate multiple pulmonary opacities. The opacities may occur in any portion of the lungs but are usually maximal in the lower zones. The lesions are usually either round in shape or show the shape of a pulmonary infarct, namely a wedge-shaped density base on the pleura and pointing to the hilum. They may have any size and frequently cavitate, a feature more easily recognized on CT. Air-bronchograms are frequently seen, particularly on CT, in all types of opacity, including the nodular lesions. The combination of multiple peripheral nodules or wedge-shaped consolidations, some of which are cavitated, and a distinct feeding vessel in the appropriate clinical setting is highly suggestive of the diagnosis of septic emboli.


Printfriendly