Immunomodulatory Effects of Vitamin D in Respiratory Tract Infections and COVID-19 in Children

Acute respiratory tract infections (ARTIs) are one of the main reasons that the pediatric population goes to the doctor. The connection between ARTI and vitamin D (VD) is currently debated by the medical community, and so far, there has been little agreement with regard to the ideal level of 25(OH)D concentration that would provide protection for the respiratory tract, or the effectiveness of its administration in the treatment of respiratory infections. The purpose of this literature review was to bring attention to the immunomodulatory and antiviral function of vitamin D and its relation to the respiratory system by examining the main ARTIs, including SARS-CoV-2. The latter has affected the pediatric population in different ways, from asymptomatic patients to severe forms with multisystem inflammatory syndrome in children (MIS-C). Although there are not much clinical data on the SARS-CoV-2 disease in the pediatric population worldwide, we tried to find out whether there is a connection between the severity of this disease, other ARTIs, and vitamin D supplementation. We also aimed to find out if 25OHD deficiency had an adverse effect on the evolution of the disease and the recovery period in the case of younger patients affected by COVID-19. For this literature review, the PICO framework was selected as the methodological approach. Our results demonstrated many methods by which this vitamin may lower the risk of ARTI with regard to the COVID-19 infection. Despite these significant advancements, more research is needed to support the idea that 25(OH)D concentration can influence the evolution of respiratory tract infections in children.

Better Safe than Sorry: Rheumatoid Arthritis, Interstitial Lung Disease, and Medication-A Narrative Review

It is well known that rheumatoid arthritis (RA) patients are at an increased risk of developing non-infectious pulmonary complications, especially interstitial lung disease (ILD); however, the clinician must keep in mind that lung disease could not only be a manifestation of the underlying condition, but also a consequence of using disease-modifying therapies. New-onset ILD or ILD worsening has also been reported as a possible consequence of both conventional disease-modifying antirheumatic drugs (DMARDs) and biologic agents. This study is a narrative review of the current literature regarding the potential risk of developing interstitial lung disease along with the administration of specific drugs used in controlling rheumatoid arthritis. Its purpose is to fill knowledge gaps related to this challenging patient cohort by addressing various aspects of the disease, including prevalence, disease features, treatment strategies, and patient outcomes.

Clinicopathological Outlines of Post-COVID-19 Pulmonary Fibrosis Compared with Idiopathic Pulmonary Fibrosis

This review brings together the current knowledge regarding the risk factors and the clinical, radiologic, and histological features of both post-COVID-19 pulmonary fibrosis (PCPF) and idiopathic pulmonary fibrosis (IPF), describing the similarities and the disparities between these two diseases, using numerous databases to identify relevant articles published in English through October 2022. This review would help clinicians, pathologists, and researchers make an accurate diagnosis, which can help identify the group of patients selected for anti-fibrotic therapies and future therapeutic perspectives.

Romanian Guidelines for the Diagnosis and Treatment of GERD-induced Respiratory Manifestations

BACKGROUND AND AIMS

Gastroesophageal reflux disease (GERD) is a common condition present in daily practice with a wide range of clinical phenotypes. In this line, respiratory conditions may be associated with GERD. The Romanian Societies of Gastroenterology and Neurogastroenterology, in association with the Romanian Society of Pneumology, aimed to create a guideline regarding the epidemiology, diagnosis and treatment of respiratory conditions associated with GERD.

METHODS

Delphi methodology was used and eleven common working groups of experts were created. The experts reviewed the literature according to GRADE criteria and formulated 34 statements and recommendations. Consensus (>80% agreement) was reached for some of the statements after all participants voted.

RESULTS

All the statements and the literature review are presented in the paper, together with their correspondent grade of evidence and the voting results. Based on >80% voting agreement, a number of 22 recommendations were postulated regarding the diagnosis and treatment of GERD-induced respiratory symptoms. The experts considered that GERD may cause bronchial asthma and chronic cough in an important number of patients through micro-aspiration and vagal-mediated tracheobronchial reflex. GERD should be suspected in patients with asthma with suboptimal controlled or after exclusion of other causes, also in nocturnal refractory cough which needs gastroenterological investigations to confirm the diagnosis. Therapeutic test with double dose proton pump inhibitors (PPI) for 3 months is also useful. GERD induced respiratory conditions are difficult to treat; however,proton pump inhibitors and laparoscopic Nissen fundoplication are endorsed for therapy.

CONCLUSIONS

This guideline could be useful for the multidisciplinary management of GERD with respiratory symptoms in current practice.

High 24-Hour Respiratory Symptoms and Low Physical Activity in the Stable COPD Romanian Cohort of SPACE Study

Objective

This study assessed the characteristics and the relationship between symptoms in any part of the 24-hour (24-h) day, physical activity level (PAL), and other clinical and functional outcomes in stable COPD patients.

Patients and Methods

Out of the 2162 patients enrolled in the SPACE study (The Symptoms and Physical Activity in COPD patients in Europe, clinicaltrials.gov NCT03031769), 406 (18.8%) were recruited from Romania. Here, we present the Romanian cohort results. Eligible patients were adults with age at least 40 years, confirmed diagnosis of stable COPD, current or former smokers with a smoking history of minimum 10 pack-years. The 24-h respiratory symptoms were assessed using Early Morning Symptoms of COPD Instrument (EMSCI), Evaluating Respiratory Symptoms in COPD (E-RS™: COPD) and Nighttime Symptoms of COPD Instrument (NiSCI). During clinical interview, patients self-evaluated PAL through Exercise as Vital Sign (EVS) and Yale Physical Activity Survey (YPAS). Physicians assessed PAL through their clinical judgment.

Results

For each combination of 2 between the early morning (EM), daytime (DT) and night-time (NT) symptoms of the 24-h day, there was a significant association (p < 0.001 for each). All symptoms significantly correlated with exacerbation history (p < 0.001 for EM and NT, p=0.002 for DT), and number of severe exacerbations (p < 0.001 for DT, p=0.001 for EM and p=0.026 for NT, respectively). The 24-h symptoms correlated negatively and significantly with PAL (p < 0.001), irrespective of the assessment used. Self-reported PAL negatively correlated with dyspnea, symptom burden, severity of disease and number of exacerbations (p < 0.001). Patients spent an average (standard deviation) of 25.8 (21.0) hours/week performing physical activity. Physicians overestimated their patients' daily PAL.

Conclusion

A negative and significant correlation between the 24-h day symptoms and PAL was identified in stable COPD patients. Physicians need to routinely assess PAL using adequate tools and start educating inactive COPD patients to optimize their disease outcomes.

Respiratory Dysfunctions in Parkinson's Disease Patients

Respiratory dysfunctions have been associated with Parkinson's disease since the first observations of the disease in 1817. Patients with Parkinson's disease frequently present respiratory disorders with obstructive ventilatory patterns and restrictive modifications, as well as limitations in respiratory volumes. In addition, respiratory impairments are observed due to the rigidity and kyphosis that Parkinson's disease patients experience. Subsidiary pulmonary complications can also appear as side effects of medication. Silent aspiration can be the cause of pneumonia in Parkinson's disease. Pulmonary dysfunction is one of the main factors that leads to the morbidity and mortality of patients with Parkinson's disease. Here, we performed a narrative review of the literature and reviewed studies on dyspnea, lung volumes, respiratory muscle function, sleep breathing disorders, and subsidiary speech and swallow impairments related to pulmonary dysfunction in patients with Parkinson's disease.

Interrelation between facial soft tissue lessions, underlying fracture patterns and treatment of zygomatic bone trauma: a 10 year retrospective study

Background

The pattern of zygomatic bone fractures varies in the literature, their features being frequently masked by the presence of associated soft tissue lesions. In this context the clinical diagnosis and the therapeutic indications can be difficult. The aim of this study was to evaluate the clinical features of zygomatic bone fractures and their interrelation with concomitant overlying soft tissue injuries, as well as to assess the type of treatment methods applied depending on the fracture pattern and the results achieved depending on the incidence rate of postoperative complications. We will use these results in order to improve the diagnosis and the establishment of correct treatment of this pathology.

Methods

A 10-year retrospective evaluation of midface fractures was performed in patients diagnosed and treated in a tertiary Clinic of Oral and Maxillofacial Surgery. Statistical analysis was performed with the MedCalc Statistical Software version 19.2 (MedCalc Software bvba, Ostend, Belgium; 53 https://www.medcalc.org; 2020). Nominal data were expressed as frequency and percentage. The comparisons of the frequencies of a nominal variable among the categories of another nominal variable were made using the chi-square test. Multivariate logistic regressions were used in order to establish the independent association between variables and lacerations/excoriations. After using the Bonferroni correction for multiple comparisons, a value of p < 0.025 was considered statistically significant.

Results

The study included 242 patients with zygomatic bone fractures. The majority of the fractures were displaced n = 179 (73.9%), closed n = 179 (73.9%) and complete n = 219 (90.5%). Hematoma was the most frequent associated soft tissue lesion n = 102 (42.1%) regardless of the fracture pattern (p = 1.000). Complete zygomatic fracture (OR – 2.68; p = 0.035) and fractures with displacement (OR – 3.66; p = 0.012) were independently associated with the presence of laceration. Fractures with displacement (OR – 7.1; p = 0.003) were independently associated with the presence of excoriation. The most frequent type of treatment applied was Gillies reduction (61.9%), followed by ORIF (30.9%). The most frequent postoperative complication was malunion secondary to Gillies treatment (4,6%).

Conclusions

Patients presenting lacerations and excoriations on clinical soft tissue examination will most frequently have an underlying complete, displaced or comminuted zygomatic fracture. In the case of displaced, open or comminuted fractures we achieved the best results secondary to ORIF treatment method, while in the case of non-displaced and closed fractures, the best results achieved were secondary to conservative treatment.

A retrospective evaluation of the treatment of viscerocranial fractures in Romania. A study of 1007 patients

AIM

The treatment of viscerocranial fractures is complex and involves orthopedic, surgical methods, or combinations of both. The aim of this study is to evaluate the treatment methods applied and the type of materials used in the case of viscerocranial fractures in our geographical area, as well as to assess postoperative complications depending on each type of treatment, the location and the characteristics of the fracture lines.

MATERIAL AND METHODS

A 10-year retrospective statistical analysis of 1007 patients treated in a Romanian university hospital was performed, the data being collected from patients' medical records.

RESULTS

The most frequent maxillofacial fractures were located in the mandible (62.16%). The zygomatic bone was the most fractured bone of the midface (44.91%). In the majority of the fractures, displacement of the fractured fragments occurred (84.40%). Most of the patients had a favorable evolution (97.8%) Orthopedic/closed treatment was the most frequent treatment applied (78.15%). This was followed by the greatest number of postoperative complications, while ORIF surgical treatment registered the smallest number of complications (p=0.209). The most frequent postoperative complication was osteitis (74.19%). The highest incidence of postoperative complications was found in the case of fractures in multiple locations and displacement of the fractured fragments (p=0.000).

CONCLUSIONS

The most effective treatment method in the case of maxillofacial fractures is ORIF surgery. The rate of postoperative complications is directly proportional to the number of fracture lines and the degree of bone displacement.

KEY WORDS

Maxillofacial, Trauma, Treatment.

Fatal rare case of measles complicated by bilateral pulmonary embolism: a case report and short literature review

Different endemic outbreaks of measles have been diagnosed worldwide during the last several years. Some have had severe and fatal complications, possibly because of decreasing vaccination rates. The present case report describes an unvaccinated boy aged 2 years 11 months who was diagnosed with severe measles complicated by pulmonary embolism (PE). Clinical examination revealed a maculopapular rash, hyperemic pharynx, Koplik’s spots, upper respiratory airway obstruction, and tachycardia with no meningeal signs of irritation. Laboratory investigations showed leukocytosis, anemia, normal liver enzyme levels, a moderately high C-reactive protein level (26 mg/L), a high erythrocyte sedimentation rate (65 mm/h), and immunoglobulin M positivity for measles. The patient was treated with antibiotic therapy (meropenem at 20 mg/kg every 8 hours) and supportive measures (anti-inflammatory drugs and intravenous rehydration). On the fourth day of hospitalization, the patient’s general condition became profoundly altered; although cardiorespiratory resuscitation maneuvers were initiated, the child died. Autopsy revealed bilateral pleural effusion with serous citrine fluid, acute purulent bronchopneumonia, bilateral hilar adenopathy, and bilateral PE. Additional research is needed to establish optimal care for pediatric patients with measles, especially when complicated by PE.

Increased Exhalated Carbon Monoxide, Smoking and Obstructive Sleep Apnea

Although exhaled carbon monoxide (CO) is studied from decades, a few studies are about its levels in smokers with obstructive sleep apnea (OSA). The average level of exhaled CO (eCO) was determined in OSA smokers and found increased significantly higher than in patients with other breathing related sleep disorders. A gender significant difference in average eCO was also noticed, with higher numbers in men, in OSA patients. A threshold of the eCO � 6 ppm has 100% specificity and 96.3% sensitivity in detection of the active smoking habit in patients with OSA. Among OSA comorbidities, only chronic obstructive pulmonary disease (COPD) seams to influence the increased eCO levels in OSA active smokers.

Study of the Total Serum Concentration of Serrum Ionized Magnesium in Children and Adolescents from Sibiu Area

Magnesium is an essential nutrient for the living organisms and plays an important part in the prevention and treatment of many diseases. It is an enzymatic cofactor for more than 300 reactions. Magnesium is essential for regulating blood pressure, muscle contraction, cardiac excitability, insulin metabolism, vasomotor tonus. Studying the way in which serum magnesium concentration varies in children and adolescents in the Sibiu area according to the reference intervals we especially set for this area. The study is a retrospective one, using approximately 4900 data from the archives of the Medical Analysis Laboratory within the Sibiu Pediatric Clinical Hospital. Serum magnesium was dosed using the Konelab Prime 30i analyser. The data from the literature was used to compare the results. The reference ranges obtained in the current study were similar to the literature studied. The percentage of patients with magnesium concentration outside the reference ranges was roughly equal for all age groups. The difference was between 1 month and 2 year-old children with very few deviations from the reference range. The results of our study reflect more accurately the real reference range for the population in the Sibiu area, helping clinicians to establish a diagnosis as quickly and accurate as possible. These results were not significantly different from the literature studied.

The Clinical Implications of Carbon Dioxide Increased Level in Arterial Blood Related to Severe Exacerbations of Chronic Obstructive Pulmonary Disease

In the evolution of patients with chronic obstructive pulmonary disease (COPD), exacerbations occur, especially, in severe stages, determining aggravated respiratory failure and decreased survival. In order to evaluate the implications of COPD exacerbations in patients with second type of chronic respiratory failure and hypercapnic encephalopathy, a prospective observational study was done among 195 COPD in patients of Targu Mures Clinical County Hospital, Romania. Inclusion criteria consisted in severe exacerbations of COPD, complicated by hypercapnia, defined by an increased level of arterial blood gas carbon dioxide (PaCO2) �45 mmHg, suggestive for the second type of respiratory failure. The increased values of PaCO2 ranged between 45 and 112 mmHg among 95 patients. The prevalence of hypercapnia in COPD patients, admitted in hospital for severe exacerbations, was high (n=91/195; 46.66%). The majority of COPD patients (93.4%) were initially hospitalized in the intensive care unit (ICU) department because of hypercapnic encephalopathy. The mortality rate was higher among patients with endotracheal tube insertion than in patients treated by noninvasive mechanical ventilation. High levels of hypercapnia, conscience disorders and respiratory acidosis may be considered factors of severity in COPD exacerbation.

Post-traumatic occipital psoriatic plaque complicated by extensive necrotizing fasciitis of the head and neck: a case report and literature review

Necrotizing fasciitis (NF) is a severe infection involving the superficial fascial layers, subcutaneous cellular tissue, and possibly skin. It usually has a fulminant evolution, rapidly leading to death in the absence of early diagnosis and aggressive surgical treatment. We herein report a rare case of NF secondary to a traumatized occipital psoriatic plaque in an alcoholic 47-year-old woman and compare this case with the published literature. The NF extended to the entire scalp, right face, and posterior and lateral cervical region. Despite the initially guarded prognosis, the patient’s survival emphasizes the importance of aggressive surgical treatment with wide excision of all necrotic structures without any aesthetic compromise.

Biochemical Features of an Acute Viral Hepatitis A Outbreak

In developing countries, outbreaks of acute hepatitis A virus (HAV) infection have a cyclic recurrence and almost 90% of children go through disease by the age of 10. Although the evolution of HAV is rarely severe, it can cause significant economic and social losses. In order to analyze clinical and biochemical characteristics of acute HAV reported diseases in Constanta county, South Eastern Romania, during the last pediatric outbreak, all cases of hospitalized children, less than 13 years old (n=578), mostly boys with residence in urban cities, were included. Cases were divided into 295 isolated cases, mean aged 6.939 years, and 283, mean aged 6.587 years, diagnosed in different foci of the outbreak. Clinical and biochemical features of an acute HAV outbreak in the foci children��s collectivities and families consisted in mild form of disease with frequent hepatomegaly, lack of jaundice and lower levels of aminotransferases and bilirubin.

Focus on the Asbestos-Related Diseases in a Pulmonology Department

Romania implemented the complete asbestos ban legislation in 2004. Like in other countries, it would be expected that asbestos-related diseases (ARD) to reaching their peak in the following years. In this study, we present the characteristics of ARD among patients admitted in the Clinical Pneumophthisiology Hospital of Constanta, Romania, during 3 years: 2015 - 2017). Previous industrial asbestos exposure in Medgidia, a town situated in Constana County, was one of the highest in Romania, but the number of ARD cases remained relatively small. This situation demands a better investigation and surveillance of all previously exposed employees based on a comprehensive occupational history and a better collaboration with the occupational health specialists.

Serum Aminotransferases and the Severity of Asthma

The serum enzymes are ideal diagnostic or prediction markers. Aspartate aminotransferase (AST), a mitochondrial and cytoplasmic enzyme, is one of the well-known markers of hepatic, myocardial or skeletal muscle cytolysis, while alanine aminotransferase (ALT) is mainly a hepatic cytoplasmic enzyme. The normal plasmatic values of AST and of ALT reflect a physiological cell turnover. Therefore, both high and low levels of serum liver enzymes might have a clinical significance. We have conducted a retrospective study targeting the association between the serum AST and ALT levels and the lung function impairment among patients with occupational asthma but without hepatic, cardiac, renal or muscular disorders. Our data show a significant relation (R = 0.54, p [0.05) between the parameters of obstructive ventilator syndrome and AST and ALT levels, respectively (R =0.42, p [0.05). If this relation is confirmed in prospective studies, serum AST and ALT could become useful markers in monitoring asthma patients.

Romanian Pilot Study of Alpha-1 Antitrypsin Detection-Feasibility and Challenges

Alpha-1 antitrypsin deficiency (AATD) is an underdiagnosed genetic disorder that manifests primarily through pulmonary and hepatic impairment. In Romania, a targeted detection program testing for AATD was implemented between October 2012 and October 2016. A cohort study enrolled all patients with indication for AATD screening (lung or liver disease, adults and children, index and non-index cases). Testing methods were mainly represented by isoelectric focusing, genotyping and/or sequencing. 620 patients (21 children) were tested (median age 50.0�16.4 years, 58.1% men), 91.9% of proved normal. A total of 50 patients were identified to be carrying a modified genotype (26 men). Hardy-Weinberg equilibrium was used for assessing the frequency of the genetic abnormalities: 1/1.08 PiMM, 1/32 PiMS, 1/28 PiMZ, 1/48 M-rare allele heterozygote, 1/3906 PiSS, 1/2770 PiZZ, 1/1000 PiSZ and 1/12346 for a Z-rare allele heterozygote. Severe AATD was present with a 1% frequency. Prevalence of abnormal genotypes estimated for each at risk category was greater in neonate hepatitis (100%), bronchitis (20%) and adult liver cirrhosis (33.3%). In conclusion, a targeted AATD detection program with this formula is feasible in Romania and will be continued with the implementation of a national registry.

Association Between Chronic Obstructive Pulmonary Disease and Sleep Apnea - Overlap Syndrome- Experience of Pulmonology Clinic Tg. Mures, Romania

Association between chronic obstructive pulmonary disease (COPD) and sleep apnea SA (overlap syndrome - OS) includes serious clinical manifestations and high mortality due to early respiratory failure, cardiovascular and metabolic complications from both diseases. 90 COPD patients (85.5% males) were strongly suspected to have concomitant SA after clinical examination and sleep questionnaires. We performed a cardio-ventilatory poligraphy during sleep. 82 patients (91.1%) from our OS group had obstructive sleep apnea (OSA), 8 patients (8.9%) mixed apnea and 20% had also OHS. 17 (18.8%) of OS were overweight and 66 (73.3%) obese. A third of them were in a very active group of age: 49 patients (54.4%) under 60 year-old and 11 patients (12.2%) between 61-65 year/old. We noted severe complication/comorbidities in our OS group: 63.3% hypertension, 43.3% core pulmonale, 31.1% arrhythmia, 32.2% cardiac failure, 38.8% dyslipidemia, 31.1% diabetes. The second night investigation permitted titration for the targeted pressures for CPAP therapy (Continuous Positive Airways Pressure). Treatment of OS patients had an interdisciplinary approach: CPAP in OSA, BPAP (Bi-level Positive Airways Pressure) in OHS, inhaled bronchodilators, treatment of cardiovascular comorbities, pulmonary rehabilitation, weight loss, tobacco/alcohol cessation counseling, and oxygen therapy in remaining hypoxemic patients. 51.2% of patients had not accessibility for long time CPAP (lack of coverage by the public health system). OS included clinical aspects of severity due to both COPD and OSA. Clinical investigation, sleep questionnaires, assessment of the diurnal somnolence and sleep cardiorespiratory poligraphy are recommended in all COPD patients. Obesity was the main risk factor for OSA in COPD patients.

Lung Function and Quality of Life in Workers with Chemical and Dust Exposure

Regarding the widely distribution of respiratory exposure hazards in occupational settings, workers have an increased risk for chronic lung diseases. For assessing the quality of life and lung function in workers exposed to chemicals and dust, St George�s Respiratory Questionnaire (SGRQ) and spirometry were performed among 40 patients, admitted in Occupational Clinic Department of Colentina Hospital, Bucharest, Romania, during February, 2017. SGRQ showed different predictors for patients according to their occupational exposure and total symptoms score correlated better with decreased spirometric parameters in defining lung function deterioration. Quality of life is earlier affected than lung function deterioration and emphasises the need of more sensitive methods for an earlier identification and better evaluation of respiratory hazards in different workplaces.

Glycosylated Hemoglobin and the Severity of Sleep Obstructive Apnea

This research revealed a strong relation between apnea- hypopnea index (AHI), average blood oxygen saturation (avSpO2) measured with the pulse oximeter, oxygen desaturation index (ODI) and glycosylated hemoglobin (HbA1c) in obstructive sleep apnea (OSA) patients, not previously diagnosed with diabetes. Data from biochemistry, fundamental biology and previous clinical monitoring reports were integrated in interpreting this relation. The analysis concluded that high levels of HbA1c limit the relevance of avSpO2 in evaluating OSA severity. ODI maintains a strong association with AHI in high levels HbA1c group.

Prognostic Intake of Molecular Markers in Lung Cancer The Pulmonologist Point Of View

Lung cancer remains one of the most frequent pathologies in Pulmonology Departments. Tumor extension, histopathological types, and treatment influence the prognosis and survival in lung cancer. Five years survival dramatically decreases for the 4th-stage of the disease. Non-small cell lung cancer (NSCLC) represents the vast majority of lung cancers. In the last decades, important findings have been made on identifying standardized molecular biomarkers that control tumor growth in lung adenocarcinoma. The discovery of new drugs led to the increased survival, even in extensive forms of the disease. The greatest advances could be obtained by targeting EGFR genetic mutations or EML4-ALK translocate in patients diagnosed with adenocarcinoma lung cancer

Differential diagnosis between occupational chronic intoxication with organic solvents and ethanol abuse by biological markers. Case report and literature review

Given the occupational exposure to substances contained in petroleum heated to high temperature, cholestatic liver disease, neurological signs and symptoms can occur. We present a case report of a male patient with no tobacco exposure or alcohol use, but with prolonged occupational exposure to petroleum vapours and natural gases like methane, propane butane who developed liver and neurologic disease, in the absence of protective equipment. Delayed diagnosis was established after 9 years of the first symptoms occurrence. Differential diagnosis with alcoholic etiology was considered and biological biomarkers were useful.

Analysis of bronchoalveolar lavage fluid in a first Romanian pulmonary alveolar proteinosis cohort

The features of bronchoalveolar lavage fluid (BALF) components and the severity of pulmonary alveolar proteinosis (PAP) were analyzed in the first Romanian cohort of patients admitted to "Marius Nasta" Institute of Pneumophtisiology, Bucharest, Romania. A six-year follow-up study based on bronchoalveolar lavage (BAL) data was performed between January 2007 to December 2012. Study cohort consisted in 20 inpatients diagnosed with PAP, based on BALF cytological findings and÷or on histopathological findings. Demographic, medical history, tobacco use, clinical and radiological features, disease progression with or without whole lung lavage (WLL) therapy were collected. Disease severity was evaluated by pulmonary function testing including spirometry, blood gas analysis, plethysmography, and diffusing capacity of the lung for carbon monoxide (DLCO), also known as transfer factor (TLCO). The cellular profile of all BALF specimens was analyzed. Statistical analysis made by SPSS version 17.0 included Student's t-test, chi-square test and ANOVA. Mean age of the subjects was 43±16.59 years, with male predominance (n=12; 60%). Diagnosis of PAP was facilitated by fiberbronchoscopy (FBS) with BAL in 90% of cases. Cytological findings of BALF revealed lower macrophages (57.26±18.19%), with a preponderance of neutrophils (17.75±19.44%) and lymphocytes (21.8±16.12%). Lower oxygen partial pressure was identified in elders, comparing to younger patients (p=0.038). Patients treated by WLL had a lower total lung capacity (TLC) and DLCO versus those who did not required WLL (p=0.009, respectively p=0.056). The severity of pulmonary abnormalities provided WLL indication was not influenced by BALF cellularity.

Distinction between mesothelioma and lung adenocarcinoma based on immunohistochemistry in a patient with asbestos bodies in bronchoalveolar fluid - case report

Asbestos is a mineral-mined form the rocks, consisting in amosite (brown asbestos), crocidolite (blue asbestos) and÷or chrysotile (white asbestos) used in many industries. Researches about the exposure to asbestos dust and asbestosis related diseases started almost a century ago. The first case report of fatal asbestosis disease was published in 1906, in England, by Dr. Hubert Montague Murray. A decade after, asbestos "curious bodies" were firstly described in the lung tissue by Cooke (1926) and McDonald (1927). Occupational exposure to asbestos is now regulated in Romania, but past exposure is still a cause of asbestosis-related diseases (ARDs), including lung cancer. A peculiar association between a lung adenocarcinoma, a previously healed pulmonary tuberculosis (PTB) disease, is reported in a 61-year-old nonsmoker white man, a former factory worker with 29 years of occupational exposure history to cement and asbestos fibers. The positive diagnosis of asbestos exposure was facilitated by asbestos bodies determined in bronchoalveolar lavage fluid. The main purpose of this case report is to describe the development of a right pleural effusion which was not revelatory for a mesothelioma but for an adenocarcinoma of the lung. An accurate morphologic and immunohistochemistry assessment of a pleural biopsy sample excluded mesothelioma and was crucial in the positive diagnosis of adenocarcinoma. In conclusion, unilateral paraneoplastic pleural effusion in a nonsmoker male with occupational exposure to asbestosis fibers was suggestive for adenocarcinoma related asbestosis of the lung. Lung cancer and malignant pleural exudate developed after a long latency cumulative retention time of asbestos fibers.

Parental environmental tobacco smoking and the prevalence of respiratory diseases in primary school children

INTRODUCTION

The inhaling tobacco smoke to which a child is exposed, in a home environmental area, could affect respiratory system.

MATERIAL AND METHODS

The aim of the study consists in detecting the prevalence of respiratory diseases in home exposure to secondhand smoke among primary school children. A 6-month prospective case-control study based on questionnaire survey was carried out among school children of "Spiru Haret" Primary School, Medgidia, Romania, with absences for respiratory diseases, related to exposure to parental passive smoking, in their home environmental. 136 school children and their families informed, consented to complete the questionnaire and were surveyed for respiratory diseases and domestic environmental tobacco smoking, from the 1st of October, 2011 to the 31st March, 2012. The method consists in collecting data about any respiratory illness events, correlating them with the questionnaire --reports of parental smoking in home environmental.

RESULTS

Participants were divided in 88 cases exposed to SHS (E) and 48 controls without exposure (NE). The most sick children with more than one episode of respiratory illness were among cases (n = 61/88; 69.31% vs 19/48; 39.58%; OR = 3.45; RR = 1.62; chi2 = 12.25; p < 0.0008). The most important source of parental passive smoking is the father (n = 67/88; 76.13%), being a single parent in most of the cases (n = 46/88; 57.95%). The prevalence of bronchial asthma was 0.34% in cases, being related with prenatal maternal smoking exposure (1.11%).

CONCLUSION

The prevalence of respiratory diseases is higher among children with environmental parental tobacco exposure, in particular, smoking father.

Progressive intraparenchymal lung nodules dissemination in a heavy smoker and seropositive rheumatoid arthritis suspected of tuberculosis relapse

Anthony Caplan first described rheumatoid lung nodules associated with pneumoconiosis in coal-miners (Caplan, 1953). Intraparenchymal lung nodules were later described in rheumatoid arthritis (RA) patients who were never exposed to coal dust and/or without pneumoconiosis. Rheumatoid lung nodules are usually detected in unselected patients: 0.2% in chest radiography and 4% in high-resolution computed tomography (Nannini et al., 2008). Patients could be reluctant to perform surgical lung biopsy for an accurate histopathological diagnosis. We present a peculiar association between a seropositive RA and a presumptive active tuberculosis (TB) disease in a 59-year-old male patient, ex-smoker with a previously healed pulmonary TB disease. The purpose of this report is to describe an unusual case of a presumptive relapse of the nodular TB disease, which progressed to an extensive nodular bilateral dissemination under anti-tuberculosis therapy, mimicking a metastatic carcinoma. The diagnosis of rheumatoid necrobiotic lung nodules was confirmed after open biopsy left pulmonary was performed. Formalin-fixed paraffin-embedded pulmonary rheumatoid nodules were processed for histology and stained with Masson's trichrome. Central structure of the removed pulmonary nodules is typical of a rheumatoid nodule with central necrosis surrounded by a palisade of macrophages. The accumulation of anthracotic pigment was noticed inside the pulmonary nodules in a RA patient without professional exposure to coal or mineral dust. This rare entity is an appearance of the rheumatoid nodules lung syndrome and anthracosis in a heavy tobacco former smoker.

Smoking, snoring and obstructive sleep apnea

Obstructive sleep apnea (OSA), with an apnea/hypopnea index (AHI) > or =5 events per hour, is recognized as an important cause of medical morbidity and mortality, being associated with a wide range of significant medical consequences, including arterial hypertension, cardiovascular diseases, metabolic diseases, neurological diseases and psychological effects. Tobacco smoking is considered a predisposing factor for pulmonary and cardiovasculary diseases and a risk factor for developing OSA. Since snoring is frequent in smokers and a common symptom, even a preclinical form of OSA, it is reasonable to speculate that smoking is an independent risk factor for snoring and may be associated with OSA. Current studies have observed there is a synergistic effect between smoking and OSA, both increasing the risk of cardiovascular disease through oxidative stress, endothelial dysfunction and abnormal inflammatory response. OSA, itself could be responsible for nicotine addiction.

[Smoking and chronic autoimmune thyroiditis]

INTRODUCTION

The chronic autoimmune thyroiditis are heterogeneous entities by the functional, lesional and evolutive point of view. Ethiopathogenic factors involved in chronic autoimmune thyroiditis are genetical factors, combines with environmental factors, hormonal factors, infectious factors etc. The exact role of smoking on the autoimmune mechanism is unclear, but smoking is known to have an antithyroid effect.

AIM

Our study tries to estimate the influence of smoking on serum levels of antithyroid peroxidase antibodies and antithyroglobulin antibodies, in a group of patients with various clinical forms of chronic autoimmune thyroiditis.

MATERIALS AND METHODS

We studied a group consists of 310 patients with chronic autoimmune thyroiditis, hospitalised in the Endocrinology Department of Constanta County Hospital, between January 2006 - December 2009. We detected serum values of antithyroidperoxidase antibodies and antithyroglobulin antibodies of our patients. We also followed the age, sex and presence of smoking in our study group. For statistical processing of the data we use Student's t-test.

RESULTS AND DISCUSSIONS

In our study group 24.28% of patients were smokers. Serum levels of antithyroid peroxidase antibodies were significantly increased (p < 0.001) in the smokers patients, compared with the nonsmokers patients. Serum levels of antithyroglobulin antibodies were significantly increased (p < 0.01) in smokers patients, compared with those who were nonsmokers.

CONCLUSIONS

Smoking increased the serum levels of antithyroid antibodies in patients with chronic autoimmune thyroiditis.

[Sternal chondrosarcoma and the complications poststernectomy]

Primary tumors of the sternum are unusual, and, of these chondrosarcoma is extremely rare. Prior cases were more frequent in men. It is the consensus that central (axial) skeletal lesions are always suspected of malignancy. It is difficult to deduce from the roengenographic and pathologic findings the presence of a sternal tumor. This case report of primary sternal chondrosarcoma illustrated an extremely rare cartilaginous lesion in a male 64 years old. Extensive sternal excision was indicated despite the apparent benignity of the tumor. This aggressive surgical method facilitated the diagnosis of a malignant tumor with moderate cellular differentiation G2 chondrosarcoma. After surgery done, bilateral pleural empiema occurred.

[Diagnosis and management of occupational asthma in the American College of Chest Physicians statement]

Occupational asthma is one of the most common work-related respiratory conditions and causes considerable morbidity and impairment of quality of life. In the general population, the occupations that contribute to asthma are concentrated in the construction industry, metal, plastic and rubber work, printing and industrial cleaning. The magnitude of the attributable risk of occupational asthma is estimate between 4 to 58% among all cases of asthma. The American College of Chest Physicians (ACCP) Consensus 2007 statement proposed to reveal how the practicing pulmonologist can know whether someone is exposed to an asthma inducer at work and how is it better to manage the diagnosis and control this disease. This current statement updates the first 1995 consensus of ACCP about professional asthma, including relevant to preventive measures and work exacerbated asthma.