Acute respiratory illness and return to sport: a systematic review and meta-analysis by a subgroup of the IOC consensus on 'acute respiratory illness in the athlete'

OBJECTIVE

To determine the days until return to sport (RTS) after acute respiratory illness (ARill), frequency of time loss after ARill resulting in >1 day lost from training/competition, and symptom duration (days) of ARill in athletes.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed, EBSCOhost, Web of Science, January 1990-July 2020.

ELIGIBILITY CRITERIA

Original research articles published in English on athletes/military recruits (15-65 years) with symptoms/diagnosis of an ARill and reporting any of the following: days until RTS after ARill, frequency (%) of time loss >1 day after ARill or symptom duration (days) of ARill.

RESULTS

767 articles were identified; 54 were included (n=31 065 athletes). 4 studies reported days until RTS (range: 0-8.5 days). Frequency (%) of time loss >1 day after ARill was 20.4% (95% CI 15.3% to 25.4%). The mean symptom duration for all ARill was 7.1 days (95% CI 6.2 to 8.0). Results were similar between subgroups: pathological classification (acute respiratory infection (ARinf) vs undiagnosed ARill), anatomical classification (upper vs general ARill) or diagnostic method of ARinf (symptoms, physical examination, special investigations identifying pathogens).

CONCLUSIONS

In 80% of ARill in athletes, no days were lost from training/competition. The mean duration of ARill symptoms in athletes was 7 days. Outcomes were not influenced by pathological or anatomical classification of ARill, or in ARinf diagnosed by various methods. Current data are limited, and future studies with standardised approaches to definitions, diagnostic methods and classifications of ARill are needed to obtain detailed clinical, laboratory and specific pathogen data to inform RTS.

PROSPERO REGISTRATION NUMBER

CRD42020160479.

Is surgical exploration necessary in asymptomatic intestinal pneumatosis after lung transplantation?

Pneumatosis intestinalis is described as gas within the bowel wall and can be a sign of bowel ischaemia with a pending perforation. The described patient presented with the incidental diagnosis of pneumatosis intestinalis with free intraperitoneal gas on CT scan. His medical history included a successful lung transplantation. We here describe the clinical decision-making and evaluate our case with previous cases in the literature.

Streptococcus intermedius: unusual presentation and complication of lung abscess

We report a case of a 54-year-old immunocompetent male who had lung abscess secondary to Streptococcus intermedius that led to discitis by contiguous spread of infection. He initially presented with constant chest pain for 6 weeks that radiated to lower back, with no fever, chills or weight loss. He denied smoking cigarettes, alcohol use or any illicit drug. On investigation, a mass was identified on the posterior medial aspect of the right lower lobe with direct infiltration into right side of the T5-T6 vertebral bodies. Histopathology identified organising pneumonia with abscess. Tissue cultures showed S. intermedius, and were negative for other microorganisms. This case highlights a rare presentation of S intermedius discitis by contiguous spread of infection from posterior right lower lobe lung abscess. S intermedius usually occurs in older patients with pulmonary infections complicated with pleural effusion or lung abscess, but can present in young patients with no clear symptoms of lung infection, like our patient.

MiR-149-5p: An Important miRNA Regulated by Competing Endogenous RNAs in Diverse Human Cancers

MicroRNAs (miRNAs) consist of a large family of small, non-coding RNAs with the ability to result in gene silencing post-transcriptionally. With recent advances in research technology over the past several years, the physiological and pathological potentials of miRNAs have been gradually uncovered. MiR-149-5p, a conserved miRNA, was found to regulate physiological processes, such as inflammatory response, adipogenesis and cell proliferation. Notably, increasing studies indicate miR-149-5p may act as an important regulator in solid tumors, especially cancers in reproductive system and digestive system. It has been acknowledged that miR-149-5p can function as an oncogene or tumor suppressor in different cancers, which is achieved by controlling a variety of genes expression and adjusting downstream signaling pathway. Moreover, the levels of miR-149-5p are influenced by several newly discovered long non-coding RNAs (lncRNAs) and circular RNAs (circRNAs). However, there is blank about systematic function and mechanism of miR-149-5p in human cancers. In this review, we firstly summarize the present comprehension of miR-149-5p at the molecular level, its vital role in tumor initiation and progression, as well as its potential roles in monitoring diverse reproductive and digestive malignancies.

Meta-analysis of whether influenza vaccination attenuates symptom severity in vaccinated influenza patients

BACKGROUND

Influenza vaccination has been associated with decreased risk of influenza-related infections. However, associations between influenza vaccination and the severity of influenza cases have not been systematically summarized. We conducted a meta-analysis to evaluate whether influenza vaccination could attenuate symptom severity in vaccinated influenza patients.

METHODS

A systematic literature search was performed using the PubMed, Web of Science, EMBASE, and Scopus databases. A quantitative synthesis of the data was conducted using a fixed/random effects model in the meta-analysis.

RESULTS

A total of seven studies, involving 6342 vaccinated and 7036 non-vaccinated patients were included. Compared with non-vaccinated, vaccinated patients were significantly less likely to develop a fever (OR = 0.66, 95% CI: 0.43-0.89), be admitted to the ICU (OR = 0.79, 95% CI: 0.64-0.97), suffer mortality (OR = 0.55, 95% CI: 0.34-0.89), stay in the ICU (WMD = -1.37, 95% CI: -2.15 to -0.60) or stay in the hospital (WMD = -0.32, 95% CI: -0.61 to -0.04).

CONCLUSION

Those benefits that could be highlighted in the communication material to enhance the uptake of influenza vaccination among both the public health nurses and the community as a whole.

Neonatal FeNO, risk factors, and respiratory morbidity in infants: A cohort study

BACKGROUND

Respiratory symptoms in infancy are more common in premature infants. Nitric oxide (NO) is involved in prenatal and neonatal lung development. Measurement of exhaled NO is easy and well-tolerated by neonates. We investigated whether neonatal exhaled NO can be used to predict subsequent respiratory symptoms. Furthermore, we sought to determine prenatal and postnatal factors associated with increased respiratory symptom risk during the first year of life in premature and mature infants.

METHODS

Tidal fractional exhaled NO (FeNO) was measured in a birth cohort (n = 135) of premature and mature infants, up to six times during the first month of life. Primary outcomes were troublesome respiratory symptoms (TRS) and doctor-diagnosed asthmatic bronchitis (AB) at 1 year of age.

FINDINGS

The correlation between FeNO and TRS changed significantly in an age-dependent pattern in moderately premature infants (p = .02). Moderately premature infants with a low FeNO of 2 ppb on postnatal Day 3 had a 48% (95% confidence interval [CI]: 17%-80%) probability of TRS, compared with a probability of 12% (95% CI: 1%-64%) for otherwise similar infants with a FeNO of 11 ppb. Respiratory syncytial virus infection and parental smoking significantly increased the TRS risk in premature infants. Parental asthma and maternal antibiotic use during pregnancy significantly increased the TRS risk in mature infants.

INTERPRETATION

An age-specific association between neonatal FeNO and respiratory symptoms was seen in moderately premature infants. TRS risk was associated with postnatal factors in premature and prenatal factors in mature infants.

Local Defence System in Healthy Lungs

Background: The respiratory system is one of the main entrance gates for infection. The aim of this work was to compare the appearance of specific mucosal pro-inflammatory and common anti-microbial defence factors in healthy lung tissue, from an ontogenetic point of view. Materials and methods: Healthy lung tissues were collected from 15 patients (three females and 12 males) in the age range from 18 to 86. Immunohistochemistry to human β defensin 2 (HBD-2), human β defensin 3 (HBD-3), human β defensin 4 (HBD-4), cathelicidine (LL-37) and interleukine 17A (IL-17A) were performed. Results: The lung tissue material contained bronchial and lung parenchyma material in which no histological changes, connected with the inflammatory process, were detected. During the study, various statistically significant differences were detected in immunoreactive expression between different factors in all lung tissue structures. Conclusion: All healthy lung structures, but especially the cartilage, alveolar epithelium and the alveolar macrophages, are the main locations for the baseline synthesis of antimicrobial proteins and IL-17A. Cartilage shows high functional plasticity of this structure, including significant antimicrobial activity and participation in local lung protection response. Interrelated changes between antimicrobial proteins in different tissue confirm baseline synergistical cooperation of all these factors in healthy lung host defence.

Unexpected cause of dyspnoea in a patient with allergic rhinitis

A defect in one part of the immune system may affect the whole system. As a result, there may be a myriad of immunological diseases, which are often masked with the one disease that has the most prominent symptoms. This case report presents a patient with long-lasting allergic rhinitis who recently developed dyspnoea in exertion with suspected asthma development. After extensive diagnostic processing, asthma was dismissed, and diagnosis of selective IgA deficiency and coeliac disease with consequential iron deficiency anaemia was established. The patient was treated with parenteral iron and a gluten-free diet, which corrected her anaemia and led to the disappearance of dyspnoea. This paper aims to show the interplay between different immunological disorders and the possible causal connection between them.

Milky pleural effusion in a neonate and approach to investigating chylothorax

Neonatal chylothorax is a rare presentation leading to significant respiratory distress, thus requiring timely diagnosis. A preterm neonate was resuscitated and ventilated, following which she clinically improved but subsequently developed respiratory distress with a right-sided pleural effusion. Interestingly, thoracentesis fluid appeared ‘milky’ with elevated triglycerides and lymphocytes, suggesting chylothorax. As fluid triglyceride level was lower than the established diagnostic criterion for chylothorax (1.24 mmol/L), a high fluid-to-serum triglyceride ratio was used as a surrogate diagnostic marker, later confirmed by lipoprotein electrophoresis. As observed in the index patient, a critically ill neonate would have a lower-than-average fat intake leading to less chylomicron production, thus lower triglyceride levels in chyle than expected, which may still fail to meet the amended cut-off limit. This case highlights the challenges in diagnosing neonatal chylothorax due to the lack of age-specific triglyceride levels in chyle and low oral fat intake in critically ill patients.

Measurements of upper and lower airway nitric oxide in healthy adults

Introduction.Nasal nitric oxide (NO) measurement can be a useful tool for monitoring upper airway diseases. However, there is a considerable lack of validation data.Aims.To evaluate the repeatability and intra-subject variations of nasal NO output (nV_NO) in healthy adults and to study its correlation with lower airway NO parameters.Methods.nV_NOwas measured in healthy non-smokers at baseline (N= 31, age: 28 ± 6 years), after 1 h (N= 15), 1 d (N= 15), 1 week (N= 17), and compared using the Bland-Altman method. At baseline, lower airway NO parameters (F_ENO, flux of NO in the conducting airways and alveolar NO concentration) were also measured and correlated tonV_NO(Spearman correlation). Multivariate regression analysis was used to assess the factors influencingnV_NO.Results.Baseline mediannV_NOwas 465 (interquartile range (IQR) = 404-536) nL min^-1. The mean differences between the baseline and repeated measurements were not significant (p> 0.05). The coefficient of repeatability (mean: 118, IQR = 88-181 nL min^-1) and coefficient of variation (mean: 9.1%) were low. We found no correlation betweennV_NOand lower airway NO parameters (p> 0.05). Sex (β= -0.52,p= 0.02) and body weight (β= -0.65,p= 0.03) influencednV_NO(model:p= 0.04,R²= 0.31).Conclusion.nasal NO output has good repeatability in healthy adults. The NO productions of lower and upper airways are not related in health, but nasal NO output seems to be affected by sex and body weight.

Cardiac tamponade and massive pleural effusion in a young COVID-19-positive adult

COVID-19 has a broad spectrum of cardiac manifestations, and cardiac tamponade leading to cardiogenic shock is a rare presentation. A 30-year-old man with a history of COVID-19-positive, reverse transcription polymerase chain reaction (RT-PCR) done 1 week ago and who was home-quarantined, came to the emergency department with palpitations, breathlessness and orthopnoea. His ECG showed sinus tachycardia with low-voltage complexes, chest X-ray showed cardiomegaly and left pleural effusion and two-dimensional echocardiography showed large pericardial effusion with features suggestive of cardiac tamponade. He was taken up for emergency pericardiocentesis which showed haemorrhagic pericardial fluid. Intercostal drainage insertion was done for left-sided large pleural effusion. After ruling out all the other causes for haemorrhagic pericardial effusion, the patient was started on colchicine, steroids, ibuprofen and antibiotics to which he responded. Both pericardial and pleural effusions resolved completely on follow-up.

Delayed presentation of a baby with an oesophageal atresia on day 14 of life

Delayed presentation of oesophageal atresia (OA) with a tracheo-oesophageal fistula (TOF) is rare. Only a few case reports and two larger case series have been published. We present a neonate who was referred to our unit on day 14 of life with a missed OA and a TOF, having survived without any feeds or total parenteral nutrition up until referral.We concluded that although such a delayed presentation is rare and avoidable, it does occur. This case highlights the necessity of good feedback to the referral hospitals with education on how to prevent this from recurring again. It also emphasises the necessity of a comprehensive clinical examination of all newborn babies. A high index of suspicion for OA with or without a TOF is essential in all babies with clinical drooling, feeding problems (from the first feed) and/or respiratory symptoms especially if combined with antenatal polyhydramnios.

Infectious laryngotracheitis of chickens: Pathologic and immunohistochemistry findings

Infectious laryngotracheitis (ILT) is an important upper respiratory disease of chickens. Gross and histologic lesions of ILT in chickens are compared to immunohistochemistry to evaluate the diagnostic test sensitivity. A total of 31 separate ILT-confirmed necropsy submissions (12 commercial meat-type flocks, 13 egg-type producers, and 6 backyard flocks) were arbitrarily selected. Each submission ranged from 1 to 18 birds, for a total of 246 chickens. Cases with available formalin-fixed tissues were selected to include a range of bird production types, ages, clinical histories, and severity of macroscopic and histologic lesions. Macroscopic findings in the respiratory tract varied from increased mucus (55.6%) to fibrinonecrotic exudate (20.3%) and hemorrhages in the larynx and trachea (13.0%). Syncytia with intranuclear inclusion bodies were present in the respiratory tract epithelium with or without hemorrhages. Sections of conjunctiva, sinus, larynx, trachea, lung, and air sac were analyzed by immunohistochemistry (IHC) to detect gallid alphaherpesvirus 1 (GaHV-1) antigen. Positive immunolabeling was detected in the cytoplasm and nuclei of syncytia and epithelial cells in 18/22 conjunctivae (82%), 12/13 sinuses (92%), 18/22 larynxes (82%), 23/25 tracheas (92%), 10/21 lungs (57%), and 3/8 air sacs (37%). Of the 34 tissues with no visible syncytia or inclusion bodies, 8 were positive by IHC. In conclusion, IHC was useful to study the viral antigen tissue distribution and support the diagnosis of ILT when the histopathologic interpretation was doubtful.

High-titre convalescent plasma therapy for an immunocompromised patient with systemic lupus erythematosus with protracted SARS-CoV-2 infection

A 39-year-old woman with systemic lupus erythematosus treated with anti-CD20 monoclonal antibody rituximab was admitted to our hospital with COVID-19 pneumonia. Despite receiving dexamethasone, she developed hypoxaemia and persistent lung opacities. As bronchoalveolar lavage was suggestive of cryptogenic organising pneumonia, high-dose corticosteroid was administered, and she received antimicrobial therapy for opportunistic infections without improvement. Reverse transcription PCR was repeatedly positive for SARS-CoV-2, and virus replication was confirmed in cell cultures. As no anti-SARS-CoV-2 antibodies were detected more than 100 days after symptom onset, she was treated with convalescent plasma with fast clinical improvement, returning home days later. Our case shows that persistent SARS-CoV-2 infection in an immunocompromised patient may be overturned with the appropriate treatment.

Triple infection with disseminated tuberculosis, invasive aspergillosis and COVID-19 in an organ transplant recipient with iatrogenic immunosuppression

A 39-year-old man with diabetes mellitus and hypertension presented two years following renal transplantation with evening pyrexia, night sweats and loss of weight. He was diagnosed with disseminated tuberculosis and invasive aspergillosis and commenced on antituberculous and antifungal therapy. Immunosuppressants except for the maintenance dose of steroids were discontinued. Two weeks later, he acquired severe COVID-19 pneumonia complicated with type 1 respiratory failure and haemodynamic instability. He was treated with non-invasive ventilation and inotropic support with a vasopressor-augmenting dose of steroids. Management challenges were diagnosing the respiratory pathologies with limited investigations, deciding on continuation of steroids in an organ transplant recipient with disseminated infection and deciding the ceiling of care in a low-resource setting given the background of multiple pulmonary insults. A multidisciplinary team decided to continue high-dose steroids and escalate to a full ceiling of care. He recovered from COVID-19 pneumonia 15 days following diagnosis and was discharged home. The potential adverse effects of steroids on tuberculosis and aspergillosis are to be monitored during follow-up.

Efficacy and cardiovascular safety of LAMA in patients with COPD: a systematic review and meta-analysis

Chronic obstructive pulmonary disease (COPD) is at present the third leading cause of death in the world. Long-acting muscarinic antagonist (LAMA) is widely used as a bronchodilator in patients with COPD. However, there is controversy concerning their cardiovascular safety. This meta-analysis aims to assess the efficacy and cardiovascular safety of LAMAs versus placebo in patients with COPD. We searched Pub Med, Embase, Cochrane Library, and Web of Science to identify studies that compared LAMA with placebo in patients with COPD. Twenty-one studies involving 24,987 participants were finally included in the analysis. There was no significant difference in the incidence of all adverse events (risk ratio (RR)=1.01, 95% CI 1.00 to 1.02, I²=15.2%) and cardiovascular events (RR=0.98, 95% CI 0.88 to 1.09, I²=4.9%) in patients treated with LAMAs versus placebo. LAMAs significantly improved trough forced expiratory volume in 1 s (weighted mean difference (WMD)=0.12, 95% CI 0.10 to 0.14, I²=86.6%), Transitional Dyspnea Index (WMD=0.75, 95% CI 0.56 to 0.94, I²=0%), and St. George's Respiratory Questionnaire (WMD=‒2.50, 95% CI ‒3.32 to ‒1.69, I²=39.8%). Moreover, LAMAs significantly reduced the incidence of exacerbation in patients with COPD (RR=0.85, 95% CI 0.79 to 0.91, I²=69.9%). LAMAs are safe therapy and play a pivotal role in improving lung function, dyspnea, and health status, and reducing the exacerbation in patients with COPD.

Respiratory Disorders in Parkinson's Disease

BACKGROUND

Parkinson's disease (PD) non motor symptoms may present early in the disease course and worsen with advancing disease. Respiratory changes can affect individuals to remain physically active, contributing to a reduction of functionality and quality of life.

OBJECTIVE

The aim of this systematic review is to synthesize evidence of respiratory disorders in patients with PD.

METHODS

An electronic search was performed up to November 2020 on PubMed-MEDLINE, Embase, Web of Science, Lilacs, Cinahl, and Cochrane using the following keyword combination: [("Parkinson disease") AND ("respiratory function tests" OR "evaluation") AND ("respiratory system" OR "respiration disorders" OR "respiratory muscles")].

RESULTS

The electronic search resulted in 601 references in English or Portuguese. The selection process and data extraction were made by two independent reviewers. We selected 19 studies including cross-sectional studies that investigated the respiratory disorders in patients with PD through pulmonary function, respiratory muscle strength, or physical capacity evaluation. We excluded studies that considered patients with other diseases. Eighteen studies evaluated the pulmonary function in patients with PD, eleven studies verified the influence of PD on respiratory muscle strength, and three studies assessed the physical capacity through functional tests.

CONCLUSION

The evidence showed that PD patients have higher chances to present a pulmonary dysfunction, either obstructive or restrictive, when compared to healthy subjects. In addition, these patients present lower respiratory muscle strength and a consequent decrease in physical capacity in endurance exercises. The respiratory impairment in PD seems to be directly related to the progression of the disease.

Interplay between SARS-CoV-2-derived miRNAs, immune system, vitamin D pathway and respiratory system

The new coronavirus pandemic started in China in 2019. The intensity of the disease can range from mild to severe, leading to death in many cases. Despite extensive research in this area, the exact molecular nature of virus is not fully recognized; however, according to pieces of evidence, one of the mechanisms of virus pathogenesis is through the function of viral miRNAs. So, we hypothesized that SARS-CoV-2 pathogenesis may be due to targeting important genes in the host with its miRNAs, which involved in the respiratory system, immune pathways and vitamin D pathways, thus possibly contributing to disease progression and virus survival. Potential miRNA precursors and mature miRNA were predicted and confirmed based on the virus genome. The next step was to predict and identify their target genes and perform functional enrichment analysis to recognize the biological processes connected with these genes in the three pathways mentioned above through several comprehensive databases. Finally, cis-acting regulatory elements in 5' regulatory regions were analysed, and the analysis of available RNAseq data determined the expression level of genes. We revealed that thirty-nine mature miRNAs could theoretically derive from the SARS-CoV-2 genome. Functional enrichment analysis elucidated three highlighted pathways involved in SARS-CoV-2 pathogenesis: vitamin D, immune system and respiratory system. Our finding highlighted genes' involvement in three crucial molecular pathways and may help develop new therapeutic targets related to SARS-CoV-2.

Omalizumab-associated eosinophilic granulomatosis with polyangiitis: cause or coincidence?

Omalizumab is an anti-IgE monoclonal antibody used in severe allergic asthma. Herein, we describe a case of eosinophilic granulomatosis with polyangiitis, which manifested 3 months after initiation of omalizumab therapy, while maintenance corticosteroid therapy dose was unchanged.

Diffuse alveolar haemorrhage with suspected idiopathic pulmonary hemosiderosis and decrease in lung diffusing capacity and chronic respiratory failure

Idiopathic pulmonary hemosiderosis (IPH) is a rare disease of unknown aetiology that causes recurrent episodes of diffuse alveolar haemorrhage (DAH). A male patient in his 50s had repeatedly experienced hemoptysis for the past 6 years, along with a decrease in the pulmonary diffusing capacity and chronic respiratory failure. After a 6-year follow-up, the patient experienced sudden exacerbation of hemoptysis and respiratory failure, and he was hospitalised. A CT of the chest revealed diffuse pulmonary infiltrates, whereas the bronchoalveolar lavage revealed hemosiderin-laden macrophages. Thus, the patient was diagnosed with DAH. As all diseases that cause DAH other than IPH were negative, the patient was suspected of IPH. He was treated with a combination of glucocorticoids and azathioprine, and his hemoptysis and chronic respiratory failure improved; however, the decrease in the pulmonary diffusing capacity did not improve. Treating adult-onset IPH with glucocorticoids and azathioprine might not improve pulmonary diffusing capacity.