Medicina pulmonar y respiratoria

This case study examines the difficulties of treating food aversion in a 9-month old child with a diagnosis of Food Protein-Induced Enterocolitis Syndrome (FPIES). Given the need to first identify a set of “safe foods” with which to work, the twin goals of doing food challenges and minimizing aversion are initially not complimentary, and require an approach outside the standard of care. The chosen plan encouraged flexibility and a positive relationship with feedingrelated items, while only introducing one food item at a time. Mom and child accomplished goals surrounding food play easily. She has successfully introduced a wide variety of new foods in small quantities and is currently working on reducing dependence on breast milk. Therapists must be prepared to modify currently accepted interventions to accommodate and support the required medical intervention.

Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH) is considered a rare syndrome and knowledge of its pathophysiology is scarce. Classified as pre-neoplastic lesion of carcinoid tumours currently there are many questions regarding the best approach to follow-up and treatment this patients. Mainly affects females, there is no apparent relationship to smoking habit and is often confused with obstructive airway disease. The diagnosis is histological and sometimes can be observed simultaneously a triple pattern consisting of DIPNECH, tumourlets and carcinoid tumour. We report the case of a 35-years-old woman, non-smoker with DIPNECH in association with typical carcinoid tumour and tumourlets.

Aim: Aim of the present study was to evaluate the effectiveness of Modified Early Warning Score (MEWS) in the outcome of In- hospital adult cardiac arrest in a tertiary hospital.

Methodology: Study design was prospective interventional study, the study duration was from September 2009 to May 2013. Location was Kasturba Hospital, Manipal and study population was patients who sustained cardiac arrests inside the hospital. Tools used were Modified Utstein style Format for standard reporting of In-hospital cardiopulmonary resuscitation and Modified early warning score chart.

Inclusion criteria: Patients with Age >18 years and patients who sustained cardiac arrest.

Exclusion criteria: Cardiac arrest in the operation theatre and Patients who were brought dead.

Objective: To describe the ecology in pleural infections, where nosocomial and community-acquired infections may have different ecology.

Methods: retrospective single center study. Any subject admitted in intensive care unit with a diagnosis of complicated pleural effusion (presence of macroscopic pus, or sero-fibrinous pleural effusion with pH <7.2 or LDH >1000 or pleural glucose <0, 4 g/L, and signs of infection or positive bacteriological sampling) were included.

Results: From 2006 to 2012, 57 patients were included. Four strains of “Multi-resistant” bacteria were reported in 3 patients with community-acquired pleural infection. As a whole 3 out of 57 (5%) patients had microorganisms (not including candida and mycobacteria) resistant to co-amoxiclav. It was not different between nosocomial and community-acquired pleural infections.

Conclusion: Our study found resistance to co-amoxiclav in 14% and “multi-drug resistance” in 8% of the patients with community-acquired pleural infection.

Chlamydia psittaci is the causative agent of psittacosis. The illness varies from a mild disease to a fatal systemic illness. In recent years the role of C. psittaci causing atypical pneumonia has become more appreciated. Here we present a severe psittacosis case resulting in acute respiratory distress syndrome (ARDS) in a woman which had contact with a pet cockatiel. Chest computed tomography scan demonstrated extensive air-space disease interspersed by airbronchograms in the dependend portions of both lower lobes. Focal areas of consolidation were also observed in the middle and superior lobes. The diagnosis was suggested on the basis of epidemiologic criteria of exposure to birds and confirmed by a serological test revealing high titers of IgG by MIF assay. In these cases psittacosis should be considered in the differential diagnosis.

A 57-year-old, postmenopausal woman was diagnosed with lung adenocarcinoma, T4N3M1b, stage IV with brain and bone metastases, in 2008. Five years following of chemotherapy and target therapy (Epidermal Growth Factor Receptor Inhibitors), the patient complained of increasing problems with lower abdominal pain, urination incontinence and abnormal vaginal bleeding. The magnetic resonance imaging examination revealed only infiltrative soft tissue tumor in the uterus, whole layered and extrauterine extension with urinary bladder involvement. There were no other abnormalities noted in the pelvic area such as colon, rectum or urological tract. Histological and immunohistochemical examinations of endocervical and endometrial biopsies revealed metastatic adenocarcinoma, with the staining reactivity as primary lung neoplasm. This is the first report of coincident metastases endometrium and cervix from primary lung cancer.

Objective: To demonstrate tracheobronchial compression caused by tortuous and dilated large and medium-sized thoracic arteries and the characteristics of these arteries by noninvasive imaging modalities.

Patients and Methods: Imaging and clinical data of six patients with tortuous, dilated large and medium-sized thoracic arteries (July 2007 to December 2013) were reviewed. The imaging data were mainly acquired by cardiac multi-slice computed tomography (MSCT) or/and cardiac magnetic resonance imaging (MRI). The number and location of tracheobronchial stenosis were noted, and the severity of stenosis was categorized. The characteristics of large and medium-sized thoracic arteries were also noted. Further, the correlation between the severity of tracheobronchial stenosis and tortuous, dilated large and medium-sized thoracic arteries was analyzed. One patient who was suspected to have arterial tortuosity syndrome underwent genetic analysis.

Results: All six patients demonstrated varying degrees of tortuosity and dilation of large and medium-sized thoracic arteries. Five were noted to have varying degrees of tracheobronchial compression and respiratory symptoms. Two have varying degrees of connective tissue abnormalities.

Conclusion: Tracheobronchial compression of tortuosity and dilation of large and medium-sized thoracic vascular origin is an uncommon and frequently unrecognized cause of respiratory distress in children. Noninvasive imaging modalities like MSCT and MRI could clearly demonstrate tracheobronchial compression and vascular abnormalities simultaneously. Attention should be given to tracheobronchial compression when disease management decisions are made, especially for determining surgical strategies and for those patients who are 6-9 months old.B. MAB is frequent in patients with COPD and is associated with hypoxemia independent of other cardiovascular risk factors.

Background: Microalbuminuria (MAB), a marker of endovascular dysfunction, is a predictor of cardiovascular events and all-cause mortality in the general population. There is evidence of vascular dysfunction in patients with chronic obstructive pulmonary disease (COPD).

Objectives: (i) To evaluate the practical role of microalbuminuria in patients with COPD. (ii) To establish relationship between degree of Microalbuminuria and Hypoxemia in COPD. (iii) To study the frequency of microalbuminuria in stable COPD patients.

Study design: The study was prospective, conducted jointly in the Department of Internal medicine and Department of Immunology and Molecular Medicine at Sher-e-kashmir institute of medical sciences, srinagar(india), over a period of two years. Stable COPD patients without any comorbidity, with wide range of airflow obstruction were taken in study. Age matched smokers of more than 10 pack-years without airflow obstruction served as controls.

Methods: We measured spot urinary albumin, smoking history, arterial blood pressure, body mass index, lung function, kidney function tests and BODE index in 97 patients with stable COPD and 94 age matched smokers with normal spirometry without known cardiovascular disease. MAB levels were compared between groups. A multivariate analysis was performed to determine the best determinants of MAB levels.

Results: Microalbuminuria was more frequent in COPD patients compared to smokers without obstruction (20.6% versus 7.4%respectively); p=0.007. There was an inverse association of the PO2 and MAB in patients with COPD (r=-0.35, p<0.0001). Multivariate analysis with MAB as the dependent variable Showed that PO2 (odds ratio: 1.003; 95%CI, 0.767-0.974; p=0.021) was only independent and significant predictor of MAB.

Conclusions: MAB is frequent in patients with COPD and is associated with hypoxemia independent of other cardiovascular risk factors.

Objective: The mandatory replacement of chlorofluorocarbons (CFCs) in pressurized metered dose inhalers (pMDIs) with non ozone depleting propellants such as hydrofluoroalkanes (HFA 134a) requires clinical testing that ensures the reformulated aerosol with HFA is as effective and well tolerated as the original CFC version. In view of this, a multicentre, randomised, parallel-group, double-blind study was conducted to compare the safety and efficacy of formoterol fumarate delivered by a MDI using the hydrofluoroalkane (HFA) 134a propellant (Cipla Ltd) with the CFC formulation (Foradil CFC pMDI, Novartis, UK) in adolescents and adults.

Methods: Patients on a stable dose of inhaled corticosteroids with a scope for improvement based on mean morning peak expiratory flow (PEF) and symptoms were randomised to receive formoterol HFA MDI 24 mg twice daily or formoterol CFC MDI 24 mg twice daily for 12 weeks. The primary efficacy variable was the mean morning PEF and secondary variables included FEV1, symptom scores, use of relief medication and safety assessments.

Results: The difference between the treatments in the adjusted mean morning PEF (formoterol HFA–formoterol CFC) was -4.68 L/min (95% CI: -13.45, 4.09). The lower limit of the 95% confidence interval was within the pre-defined limit (20 L/min) set for non-inferiority. The results of the secondary endpoints supported the findings of the primary endpoint. The incidences of adverse events (AEs) were similar for both formulations.

Conclusion: The results of this study confirm that formoterol HFA pMDI is as effective as formoterol CFC pMDI in adolescents and adults.

Common variable immunodeficiency(CVID) is a type of primary humoral immunodeficiency which is generally diagnosed at childhood. Recurrent sinopulmonary infections are early presentations of disease. Some of the patients are diagnosed in adulthood. In addition to frequent infections, autoimmune phenomena may occur in about 22% of patients. Most common autoimmune findings are autoimmune rombocytopenic purpura, hemolytic anemia rheumatoid arthritis and sicca syndrome. Splenomegaly, granulomatous infiltrations, lymphadenopathy may be seen in the course of the disease. Increased risk of malignancies is reported in CVID. Hodgkin lymphoma, most common, intestinal and uterine adeno carcinoma and rarely neuroendocrine tumors are reported with CVID. We report a 65 year-old woman who had diagnosed as rheumatoid artritis, Sjogren syndrome and idiopathic thrombocytopenic purpura. She wasdiagnosed as CVID at the age of 65. After IVIG therapy, rheumatologic diseases had stabile course, but she was diagnosed lung adenocarcinoma 3 year after her diagnosis.

Scoring systems are used in the Intensive Care Units (ICU) to provide clinical information about the severity of a disease and an estimate in hospital mortality rate. Scoring systems involves the collection of medical and clinical data regarding a patient and each data variable is assigned points. The data includes information such as organ specific information, diseases, treatments, comorbidity, and interventions. The data variables are often stratified in tables for allocating points. These points are then summated and adjusted with different weighting to give the overall score.

Benign endobronchial neoplasms are rare tumors of the tracheobronchial airways. These neoplasms are mostly slow growing and usual presentation is related to bronchial obstruction. Most patients present with symptoms such as, wheezing, cough, chest discomfort, hemoptysis or recurrent pneumonias. Radiographic findings may demonstrate, endobronchial lesions, atelectasis, pneumonia, bronchiectasis and in some instances even mediastinal shift. Imaging modalities are often non-specific. These lesions can lead to complications stemming from obstruction or asphyxiation, massive hemoptysis; requiring urgent surgical management. It is imperative to recognize their presence in a timely manner so that the appropriate intervention may be instituted. The reemergence of rigid bronchoscopy has bolstered the armamentarium of pulmonologists in diagnosis and management of such lesions. We review the clinical characteristics, diagnostic modalities and latest advancement in treatments and outcomes of benign endobronchial tumors.

The presence of both Tuberculosis and primary lung cancer in the same person is extremely rare phenomenon. Tuberculosis has been known to occur during the treatment of lung malignancy due to immunosuppression but the simultaneous demonstration of both etiologies in same biopsy during investigation of pleural effusion is extremely uncommon.

The Alveolar Stress Index is an under explored tool, promising and may help to prevent the deleterious effects of mechanical ventilation. The aim of this study was to describe the importance of Alveolar Stress Index tool, as well as aspects in ventilatory support. This tool evaluates the pressure-volume loop, which, although measures the pulmonary mechanical stress, it does not consider the heterogeneity of the respiratory system. The Alveolar Stress Index, checked in screen monitor of mechanical ventilation equipments, facilitates the detection of alveolar collapse zones (alveolar stress index <0.9) or overdistension (alveolar stress index >1.1) of lung areas. If the index value indicates alveolar collapse (atelectrauma=pulmonary lesion caused by the cyclic opening and closing of alveolar units and distal airways), it is recommended to increase the PEEP (Positive end-expiratory pressure). On the other hand, if the value indicates alveolar distension (volutrauma=pulmonary lesion induced by high tidal volume, thus causing the distension of the lung parenchyma), the initial orientation is to decrease the tidal volume. It is worth mentioning that the intention of measuring alveolar stress index is not to replace other parameters, but to add it to patient monitoring, to the median and multicompartmental observation of the ventilated area, considering the heterogeneity of lung ventilation distribution, so that more tools are available to the professional, thus avoiding or hindering lung injuries, when under mechanical ventilation.

Traumatic lung herniation through the chest wall is a rare clinical entity. Trauma may cause displacement, distortion and deficiency to the tissues of the chest wall which aids lung herniation. Here, we present a 68 year old gentleman who has sustained blunt injury to the left chest due to fall from a height after alcohol intake. He was treated with analgesics for musculoskeletal pain and then he was treated with antiplatelet for suspected angina. CT thorax shows a herniating left lower lobe that results from a defect in the sixth intercostal space and dislocation of the rib at the costochondral junction. Surgical repair for the defect was performed successfully and the patient was discharged home on the 6th post-operative day. There was no evidence of recurrent hernia at his 3-month follow-up visit.

Clinical case of progression of pulmonary tuberculosis on a background of therapy with oral antimycobacterial drugs is presented for your information. Malabsorption of oral formulations was confirmed during treatment, allowing to change the treatment strategy and to cure the patient.

Diffuse alveolar hemorrhage (DAH) caused by immune and non-immune etiological factors, characterized by diffuse alveolar consolidation often presents with the clinical triad of dyspnea, hemoptysis, anemia, as a result of the distruption of the alveolocapillary membrane of the lung. We aimed to present above 65 yaears 4 cases followed in our clinic with diffuse alveolar hemorrhage as a rare complication of uncontrolled use of anticoagulant (warfarin) therapy. The cases was diagnosed as diffuse alveoler hemorrahage based on clinical, radiological and bronghoscopic data. After warfarin treatment was withdrawn, clinical and radiological signs recovered rapidly and the existent situation was thought to be DAH related with warfarin use after excluding other reasons. We think that the current cases is a rare disease of warfarin therapy leading to DAH.

Introduction: In selected patients superior survival has been observed when treated aggressively for lung cancer and brain metastasis (BM). The aim of the study was to evaluate treatment-modalities and survival in our region retrospective.

Method: Retrospectively we compared survival for lung cancer patients treated either with microsurgery or Gamma knife surgery (GKS) for BM to a control group (N=510) patients with lung cancer stage IV and a mean age of 68 years.

Results: 42 patients with non-small cell lung cancer were included, 22 (52%) treated with microsurgery and 20 (45%) with GKS for BM. Patients treated aggressively for lung cancer and BM had a significant survival-benefit, 21 months (CI 95%: 9.4-32.6) vs. 4 months in the control group (CI 95%: 3.5-4.5) (p<0.001). Treatment with microsurgery showed a survival-benefit compared to GKS, 33 months (CI 95%: 15.7-50.2) vs. 15 months (CI 95%: 6.0-23.9). A later onset of BM was associated with a survival-benefit 24.6 months (CI 95%: 18.6-30.6) vs. 10.2 months (CI 95%: 4.4-16.1). Prognostic factors were age and the number of BM however patients with 3-4 BM had still a survival benefit (20% 2 years survival) compared to stage IV.

Conclusion: Lung cancer patients with BM, also more than 1, show a significant better overall survival after receiving aggressive BM treatment. The size of the BM seems to be less important.