25850480
Aspergillus hypersensitivity in patients with chronic obstructive pulmonary disease: COPD as a risk factor for ABPA?
Allergic bronchopulmonary aspergillosis (ABPA) is a pulmonary disorder caused by hypersensitivity to Aspergillus fumigatus which primarily complicates the course of asthma and cystic fibrosis. There is a theoretical possibility that patients with chronic obstructive pulmonary disease (COPD) can also develop Aspergillus hypersensitivity (AH) and/or ABPA. The aim of this prospective case-control study conducted in the Chest Clinic was to evaluate the prevalence of AH/ABPA in patients with COPD. Two hundred subjects with COPD (17, 62, 74, 47; GOLD guidelines stages I–IV respectively) and 100 healthy volunteers were screened with an Aspergillus skin test. Patients were said to have AH if they demonstrated immediate cutaneous hyperreactivity to A. fumigatus antigen and those with positive responses were further investigated for ABPA. Of this patient population there were 179 (89.5%) males and 21 (10.5%) females with a mean age of 57.1 in the COPD arm and 88 males and 12 females with a mean age of 52.3 in the control arm. AH was found in 17 (8.5%) patients with COPD as compared to none in the control group. Two (1.0%) COPD patients fulfilled the serologic criteria for the diagnosis of ABPA. On univariate analysis, age of the patient, duration of COPD, smoking index and the COPD severity did not predict the occurrence of AH. On the basis of this study we concluded that AH/ABPA can occur in patients with COPD, and it is probable that COPD could be a predisposing factor for AH/ABPA. The clinical significance of AH and ABPA in COPD remains unclear.
45999589
Noninvasive ventilation in acute heart failure.
22528299
Pulmonary hypertension as a presenting manifestation of allergic bronchopulmonary aspergillosis.
The case of a 46-year-old lady who presented with respiratory failure and pulmonary hypertension in the absence of clinical signs of asthma or bronchiectasis, and in whom a diagnosis of allergic bronchopulmonary aspergilloma [ABPA] was made subsequently on the basis of radiological and laboratory investigations is reported. Symptomatic and objective improvement was seen with corticosteroid therapy. To the best of the authors' knowledge, such an occurrence has not been reported previously. This case highlights the importance of keeping a high index of suspicion while investigating a patient with pulmonary hypertension in whom the aetiology is not apparent on initial evaluation. Identification of the disease, in its early-stage, can prevent progression to bronchiectasis and fibrotic lung disease, and thus, patients can be saved from the morbidity related to end-stage disease.
3038618
Is the mortality higher in the pulmonary vs the extrapulmonary ARDS? A meta analysis.
BACKGROUND AND AIM
ARDS can occur from the following two pathogenetic pathways: a direct pulmonary injury (ARDSp); and an indirect injury (ARDSexp). The predisposing clinical factor can influence the pathogenesis and clinical outcome of ARDS. This metaanalysis was aimed at evaluating whether there is any difference in mortality between the two groups.


METHODS
We searched the MEDLINE, EMBASE, and CINAHL databases for relevant studies published from 1987 to 2007, and included studies that have reported mortality in the two groups of ARDS. We calculated the odds ratio (OR) and 95% confidence interval (CI) to assess mortality in patients with ARDSp vs patients with ARDSexp and pooled the results using three different statistical models.


RESULTS
Our search yielded 34 studies. In all, the studies involved 4,311 patients with 2,330 patients in the ARDSp group and 1,981 patients in the ARDSexp group. The OR of mortality in ARDSp group compared to the ARDSexp group was 1.11 (95% CI, 0.88 to 1.39), as determined by the random-effects model; 1.04 (95% CI, 0.92 to 1.18), as determined by the fixed-effects model; and 1.04 (95% CI, 0.92 to 1.18), as determined by the exact method, indicating that mortality is similar in the two groups. The mortality was no different whether the studies were classified as prospective (OR, 1.15; 95% CI, 0.87 to 1.51) or retrospective (OR, 1.01; 95% CI, 0.61 to 1.69); small (OR, 1.11; 95% CI, 0.77 to 1.60) or large (OR, 1.1; 95% CI, 0.82 to 1.49); or observational (OR, 1.10; 95% CI, 0.82 to 1.49) or interventional (OR, 0.97; 95% CI, 0.79 to 1.19). There was methodological and statistical heterogeneity (I(2), 50.9%; 95% CI, 21.3 to 66.2%; chi(2) statistic, 67.22; p = 0.0004).


CONCLUSIONS
The results of this study suggest that there is no difference in mortality between these two groups. Further studies should focus on specific etiologies within the subgroups rather than focusing on the broader division of ARDSp and ARDSexp.
12010523
What are high-flow and low-flow oxygen delivery systems?
To the Editor:

We read with interest the article, “A Pilot Study of Normobaric Oxygen Therapy in Acute Ischemic Stroke.”1 However, we have certain reservations with the terminology and the method of oxygen delivery used by the authors.

First, regarding the terminology of “high-flow” oxygen used by the authors, the authors mention the flow rates but not the oxygen delivery system used. An oxygen delivery system is a device used to administer, regulate, and supplement oxygen to a subject to increase the arterial oxygenation. In general, the system entrains oxygen and air to prepare a fixed concentration required for administration. Oxygen delivery systems are generally classified as low-flow or variable-performance devices and high-flow or fixed-performance devices.2 Low-flow systems provide oxygen at …
26068481
Efficacy and safety of iodopovidone pleurodesis through tube thoracostomy.
OBJECTIVE
To evaluate the efficacy and safety of iodopovidone as an agent for pleurodesis through tube thoracostomy in patients with recurrent pleural effusions and pneumothorax.


METHODS
This was a prospective study in which pleurodesis was performed with a solution of 20 mL 10% iodopovidone and 80 mL normal saline solution infused through a tube thoracostomy and left in the pleural cavity for 4 h.


RESULTS
A total of 64 patients (34 men) with a mean (+/-SD) age of 47.1 +/- 15.4 years were included. There were 37 cases of pleural effusion and 27 of pneumothorax. A complete response (neither reaccumulation of fluid nor recurrence of pneumothorax) was obtained in 32 (86.5%) patients with pleural effusion and 25 (92.6%) patients with pneumothorax. A second procedure (i.e. repeated pleurodesis) was attempted successfully in four patients in the pleural effusion group. All patients experienced chest pain to a varying degree as recorded on a Visual Analogue Scale (median 50.5, range 10-95). Seven patients developed fever and one immunocompromised patient developed empyema following the procedure. There were no recurrences at a median follow up of 5 months (range 3-15 months) in the pleural effusion group, and 13 months (range 6-24 months) in the pneumothorax group.


CONCLUSIONS
Iodopovidone can be used as an effective and safe agent for (chemical) pleurodesis (through tube thoracostomy), which is inexpensive and readily available.
21105377
Is continuous veno-venous hemofiltration for acetaminophen-induced acute liver and renal failure worthwhile?
We describe a patient with acute liver and renal failure secondary to acetaminophen and chronic alcohol abuse who was treated aggressively with oral acetylcysteine, continuous renal replacement therapy, glucose and branched-chain amino acid intravenous feeding and ventilatory support. The patient had a predicted mortality of > 95% without liver transplantation however, with intensive ventilatory, renal, and nutritional support he made a complete recovery. We discuss the benefits of aggressive supportive therapy and suggest that continuous renal replacement therapy may allow gentle fluid removal, excellent control of cerebral edema and intravenous feeding that may favorably influence prognosis.
17899148
Diagnosing hypertension by intradialytic blood pressure recordings.
BACKGROUND AND OBJECTIVES
The diagnosis of hypertension among hemodialysis patients by predialysis or postdialysis blood pressure (BP) recordings is imprecise and biased and has poor test-retest reliability. The use of intradialytic BP measurements to diagnose hypertension is unknown.


DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS
A diagnostic-test study was done with interdialytic ambulatory BP as reference standard. Index BP recordings tested were: predialysis (method 1), postdialysis (method 2), intradialytic (method 3), intradialytic including predialyis and postdialysis (method 4), and the average of predialysis and postdialysis (method 5). Each index BP was recorded over six consecutive dialysis treatments.


RESULTS
There were differences among index BP measurements in reproducibility, bias, precision, and accuracy. Method 4 was the most reproducible (intraclass correlation coefficient = 0.70 for systolic and diastolic BP). All 5 measurement methods overestimated 44-h ambulatory systolic BP. Methods 2, 3, or 4 overestimated ambulatory systolic BP by only a small amount. Method 4 was the most precise and accurate. For diagnosis of hypertension, BP cut-point by method 4 of 135/75 mmHg, had a sensitivity of 90.4% and specificity of 75.9% for systolic BP (area under ROC curve 0.90). Median cut-off systolic BP of 140 mmHg from a single dialysis provides approximately 80% sensitivity and 80% specificity in diagnosing systolic hypertension; a median cut-off diastolic BP of 80 mmHg provides approximately 75% sensitivity and 75% specificity in diagnosing diastolic hypertension.


CONCLUSIONS
Consideration of intradialytic BP measurements together with predialysis and postdialysis BP measurements improves the reproducibility, bias, precision, and accuracy of BP measurement compared with predialysis or postdialysis measurements.
10080320
Unfavourable results with distraction in craniofacial skeleton
Distraction osteogenesis has revolutionised the management of craniofacial abnormalities. The technique however requires precise planning, patient selection, execution and follow-up to achieve consistent and positive results and to avoid unfavourable results. The unfavourable results with craniofacial distraction stem from many factors ranging from improper patient selection, planning and use of inappropriate distraction device and vector. The present study analyses the current standards and techniques of distraction and details in depth the various errors and complications that may occur due to this technique. The commonly observed complications of distraction have been detailed along with measures and suggestions to avoid them in clinical practice.
42063247
Prognostic importance of clinic and home blood pressure recordings in patients with chronic kidney disease.
Blood pressure (BP) measured only in the clinic substantially misclassifies hypertension in patients with chronic kidney disease (CKD). The role of out-of-clinic recordings of BP in predicting end-stage renal disease (ESRD) and death in patients with CKD is unknown. A prospective cohort study was conducted in 217 Veterans with CKD. BP was measured at home and in the clinic by 'routine' and standardized methods. Patients were followed over a median of 3.5 years to assess the end points of total mortality, ESRD or the composite outcome of ESRD or death. Home BP was 147.0+/-21.4/78.3+/-11.6 mmHg and clinic BPs were 155.2+/-25.6/84.7+/-14.2 mmHg by standardized method and 144.5+/-24.2/75.4+/-14.7 mmHg by the 'routine' method. The composite renal end point occurred in 75 patients (34.5%), death in 52 patients (24.0%), and ESRD in 36/178 patients (20.2%). One standard deviation (s.d.) increase in systolic BP increased the risk of renal end point by 1.27 (95% confidence interval (CI) 1.01-1.60) for routine clinic measurement, by 1.69 (95% CI 1.32-2.17) for standardized clinic measurement and by 1.84 (95% CI 1.46-2.32) for home BP recording. One s.d. increase in home systolic BP increased the risk of ESRD by 1.74 (95% CI 1.04-2.93) when adjusted for standardized clinic systolic BP, proteinuria, estimated glomerular filtration rate, and other risk factors. In patients with CKD, BPs obtained at home are a stronger predictor of ESRD or death compared to BPs obtained in the clinic. Systolic home BP is an independent predictor for ESRD.
18890065
Sleep and activity in chronic kidney disease: a longitudinal study.
BACKGROUND AND OBJECTIVES
Commonly sleep is disrupted and physical activity is restricted among patients with CKD and those on long-term dialysis. However, few studies have assessed patients longitudinally.


DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS
We compared the prevalence of sleep disturbances measured both subjectively using a questionnaire and objectively using actimetry among patients with CKD (n = 145), those on hemodialysis (n = 116), and people without kidney disease (n = 19). Activity level during the day was measured using actimetry, and patients were then followed for up to 2 years.


RESULTS
Compared with people without kidney disease, patients with CKD not on dialysis had disruption of sleep that was independent of several risk factors. However, disrupted sleep was correlated with neither estimated GFR in cross-sectional nor longitudinal assessment. Those on hemodialysis had sleep disruption that was of much greater severity than that found among those with CKD not on dialysis. Furthermore, missing or shortening the prescribed duration of dialysis was associated with greater severity of sleep disturbance in cross-sectional but not in longitudinal assessment. Day-time activity declined both in duration and intensity from controls to CKD to hemodialysis.


CONCLUSIONS
The loss of kidney function is related to both reduced duration and intensity of day time physical activity. Although patients with CKD have disrupted sleep, this is independent of estimated GFR. However, compared with those with CKD, dialysis patients have more severely disrupted sleep; this is related to missing dialysis. Thus, shortening patients' dialysis may reduce their sleep.