Clinical identification of malignant pleural effusions

INTRODUCTION

Pleural effusions frequently signal disseminated cancer. Diagnostic markers of pleural malignancy at presentation that would assess cancer risk and would streamline diagnostic decisions remain unidentified.

METHODS

A consecutive cohort of 323 patients with pleural effusion (PE) from different etiologies were recruited between 2013 and 2017 and was retrospectively analyzed. Data included history, chest X-ray, and blood/pleural fluid cell counts and biochemistry. Group comparison, receiver-operator characteristics, unsupervised hierarchical clustering, binary logistic regression, and random forests were used to develop the malignant pleural effusion detection (MAPED) score. MAPED was validated in an independent retrospective UK cohort (n = 238).

RESULTS

Five variables showed significant diagnostic power and were incorporated into the 5-point MAPED score. Age > 55 years, effusion size > 50% of the most affected lung field, pleural neutrophil count 〈 2,500/mm3, effusion protein 〉 3.5 g/dL, and effusion lactate dehydrogenase > 250 U/L, each scoring one point, predicted underlying cancer with the area under curve(AUC) = 0.819 (P < 10-15) in the derivation cohort. The integrated discrimination improvement of MAPED scores showed an increase compared to cytology (p <0.001). Decision curve analysis indicated that the MAPED score generated net clinical benefit. In the validation dataset, the AUC of MAPED scores was 0.723 ( P = 3 × 10-9) for the MAPED score. Interestingly, MAPED correctly identified 33/42(79%) of cytology-negative patients that indeed had cancer.

CONCLUSIONS

The MAPED score identifies malignant pleural effusions with satisfactory accuracy and can be used complementary to cytology to streamline diagnostic procedures.

CONDENSED ABSTRACT

Diagnostic markers for malignant pleural effusions remain uncertain. The MAPED score identifies malignant pleural effusions and complements cytology and confers no additional risk to the patient or cost to the healthcare system.

The impact of osteoporosis and vertebral compression fractures on mortality and association with pulmonary function in COPD: A meta-analysis

OBJECTIVE

Osteoporosis is highly prevalent among patients with chronic obstructive pulmonary disease (COPD) and most commonly presents as a vertebral compression fracture (VCF). Our objective was to quantify the effect of osteoporosis and VCFs on the mortality and pulmonary function tests (PFTs), such as forced expiratory volume in 1 second (FEV₁) and forced vital capacity (FVC), of patients with COPD.

METHODS

A PubMed/Medline search was conducted using the search terms "chronic obstructive pulmonary disease", "osteoporosis" and "vertebral compression fracture". Meta-analyses were conducted to evaluate the differences in mortality and PFTs between patients with COPD with and without osteoporosis or VCFs, according to PRISMA guidelines. PROSPERO registration: CRD42019120335.

RESULTS

Of the 896 abstracts identified, 27 studies describing 7662 patients with COPD of which 1883 (24.6%) had osteoporosis or VCFs, were included. Random effects model analysis demonstrated that patients with COPD and osteoporosis or VCFs had an increased OR for mortality of 2.40 (95% CI: 1.24; 4.64, I²=89%, P<0.01), decreased FEV₁/FVC with a mean difference of -4.80% (95% CI: -6.69; -2.90, I²=83%, P<0.01) and decreased FEV₁, with a mean difference of -4.91% (95% CI: -6.51; -3.31, I²=95%, P<0.01) and -0.41 L (95% CI: -0.59; -0.24, I²=97%, P<0.01), compared to control subjects. Apart from FEV₁ (liters) in subgroup 1 (P=0.06), all subgroup analyses found significant differences between groups, as did sensitivity analysis of low risk of bias studies.

CONCLUSION

Osteoporosis and VCFs are associated with a significant reduction in survival and pulmonary function among patients with COPD.

Bronchoscopic, non-interventional management of hemoptysis in resource limited settings: insights from the literature

The non-invasive management of clinically significant hemoptysis by bronchoscopy remains a therapeutic challenge. Various agents have been used endobronchially in order to control hemoptysis, such as cold saline, tranexamic acid, and epinephrine. This review summarizes all available data in that view, especially in resource limited settings, where more advanced means of controlling hemoptysis are not available.

Measles-associated pneumonia and hepatitis during the measles outbreak of 2018

Background Between 2017 and 2018, Greece experienced a measles outbreak, affecting >3000 patients, most of which were unvaccinated. Measles-associated pneumonia (MAP) is the most common serious compilation of the disease, but very few recent reports regarding its presentation are available. Materials and Methods Between January and May 2018, 11 adult patients presented to our department with acute measles virus infection, hypoxia and findings on chest X-ray. Clinical, laboratory and radiological data were collected and assessed. Nine out of eleven patients had hypoxic respiratory failure. Other complications included hepatitis, cholestasis and myositis, which were observed in the majority of patients. All patients received supplementary oxygen administration, whereas five patients required continuous positive airway pressure ventilation. Scoring of the radiological examinations performed was most notable for the presence of reticular opacities and consolidations. Statistical analysis demonstrated a significant association between PaO2/FiO2 values and the presence of reticular opacities, with PaO2/FiO2 decreasing as the mean value of the reticular opacities score increased (P = .02). Conclusion To our knowledge, this is the first report demonstrating an association between PaO2/FiO2 values and the presence of reticular opacities in patients with MAP. MAP should be suspected in any patient presenting with acute onset hypoxaemia and a reticular pattern on radiological examination, especially in outbreak settings. What is known Measles infections are on the rise in Europe, with epidemics affecting several European countries, resulting from suboptimal immunisation. The most common serious complication of measles is pneumonia, which is more common in adult patients and can cause significant morbidity. It is the most common cause of death due to measles. What is new In this report, we present 11 adults with measles-associated pneumonia, who presented with the combination of acute measles virus infection, hypoxia and findings on chest X-ray. To our knowledge, this is the first report demonstrating an association between the severity of hypoxaemia and the presence of reticular opacities on chest imaging studies.

Osteonectin as a screening marker for pancreatic cancer: A prospective study

Objective Osteonectin plays a central role in various processes during the development of pancreatic adenocarcinoma. This prospective pilot study was performed to determine the feasibility of serum osteonectin as a screening tool for pancreatic cancer. Methods Blood samples were collected from 15 consecutive patients with newly diagnosed pancreatic cancer and 30 matched healthy controls. Serum osteonectin was measured using an osteonectin enzyme-linked immunosorbent assay kit. The primary outcomes were the diagnostic performance of serum osteonectin and the threshold value for differentiation of patients from controls. Results The median/quartile range of serum osteonectin in patients and controls were 306.8/288.5 ng/mL and 67.5/39.8 ng/mL, respectively. Osteonectin concentrations significantly differed among the study groups. A plasma osteonectin concentration of >100.18 ng/mL as selected by the receiver operating characteristic curves demonstrated an estimated area under the curve of 86% for prediction of pancreatic cancer. Tumour size was a significant predictor of serum osteonectin. A statistically significant difference in serum osteonectin between T1/T2 and T3/T4 tumours was found. Post-hoc comparisons revealed statistically significant differences in the serum osteonectin among the control, T1/T2, and T3/T4 groups. Conclusion Osteonectin may be used as a screening tool for pancreatic cancer, although this must be validated in prospective studies.

Association between the severity of newly diagnosed obstructive sleep apnea and subclinical carotid atherosclerosis in patients without overt cardiovascular disease

OBJECTIVE

Obstructive Sleep Apnea (OSA) has been associated with both subclinical and accelerated atherosclerosis; however, it still remains unknown whether this association is unique or is mediated by the higher burden of co-existing cardio-metabolic disorders frequently seen in patients with OSA.

PATIENTS AND METHODS

A total of 40 subjects without clinically diagnosed cardiovascular disease (CVD) referred for polysomnography test were included in the study. Subjects with apnea/hypopnea index (AHI > 15/h) were classified as moderate/severe OSA. Subclinical changes in carotid atherosclerosis were assessed using mean carotid intima-media thickness (cIMT) and presence of atheromatic plaques on both carotid arteries. The measurement was performed using B-mode ultrasonogram. Framingham risk score was used in the approximation of cardiovascular risk.

RESULTS

The mean age of our cohort was 56.8 years, 70% (n = 28) of whom were males. Moderate/severe OSA was diagnosed in 21 subjects. Both groups were well matched in terms of clinical and demographic characteristics, and cardiovascular risk profile, as shown in their respective Framingham risk scores (10.4 ± 6.6 vs. 11.8 ± 8.8, p = NS). Patients with moderate/severe OSA had a higher mean AHI, 3% oxygen desaturation index, and lower minimum nocturnal oxygen saturation than controls. No significant differences were detected in terms of C-reactive protein levels. The two groups had similar cIMT (0.66 ± 0.17 vs. 0.75 ± 0.20 p = 0.33) and presence of atheromatic plaque (50% vs. 45%, p = 1.00).

CONCLUSIONS

Our study suggests that among patients with similar cardiovascular risk profile and free of overt CVD, the severity of newly diagnosed OSA was not correlated with increased inflammation or subclinical carotid atherosclerosis.

The impact of obstructive sleep apnea syndrome on renin and aldosterone

OBJECTIVE

Obstructive Sleep Apnoea Syndrome (OSAS) is a respiratory disorder characterized by recurrent airflow obstruction caused by total or partial collapse of the upper airway. OSAS is an established independent factor of cardiovascular risk together with other risk factors such as smoking and increased lipids. The aim of our study was to measure serum levels of aldosterone and renin in OSAS patients that did not suffer from arterial hypertension and compare them to matched healthy subjects in order to reveal the impact of chronic intermittent hypoxia on the renin-angiotensin-aldosterone system.

PATIENTS AND METHODS

The patients that enrolled in this study were 19 OSAS patients who had undergone overnight polysomnography and had an Apnoea Hypopnoea Index (AHI) greater than 10 events/hour. They were compared to 20 healthy non-OSAS closely matched controls. Serum aldosterone and direct renin concentration were measured by radioimmunoassay.

RESULTS

Aldosterone concentration follows a diurnal variation; therefore, all blood samples were obtained at the same time (6 AM). There were no significant differences in serum aldosterone levels between the two studied groups of OSAS patients and the healthy subjects group (140.6 pg/ml ± 25.2 vs. 133.2 pg/ml ± 18.5 with p = 0.223). Similar were the results for the renin levels (25.0 ± 6.9 vs. 24.9 ± 4.4 with p = 0.360).

CONCLUSIONS

Our study suggests that patients with OSAS, but without existing hypertension have aldosterone and renin levels similar to healthy subjects. According to our findings a direct connection between OSAS and the development of arterial hypertension may not be established via sympathetic system activation.

Pleural mesothelioma in a young male patient

We present the case of a 33-year-old male patient suffering from lymphocytic pleural effusion, as a result of pleural mesothelioma. Mesothelioma is a malignant tumor of the pleura that is mainly caused by chronic exposure to asbestos fibers and more than 40 years of exposure are needed to develop the disease. Early studies on the relationship of asbestos and mesothelioma were issued in the 1960s. Fibers migrate from the parenchyma of the lung to the visceral pleura. It is widely known that asbestos is an oncogenic factor which can cause damage to DNA. A chest x-ray may reveal pleural effusion with or without pleural thickening, whereas a chest CT may also reveal pleural thickening, uniform and/or lobular. Specific tests, such as immunohistochemical staining, are used in order to help differential diagnosis. Extrapleural pneumonectomy is used as a therapeutic option which involves removal of the lung as well as both the visceral and parietal pleura, the affected part of the pericardium and diaphragm. Surgery should be followed up by radiotherapy and chemotherapy. The surgery may lead to a mean survival rate of approximately 9-21 months. The case presented underlines that in the event of pleural effusion with a lymphocyte type physicians should consider the possibility of a pleural mesothelioma during differential diagnosis, even in relatively young patients.

The impact of obstructive sleep apnea syndrome severity on physical performance and mental health. The use of SF-36 questionnaire in sleep apnea

OBJECTIVES

Obstructive sleep apnea syndrome (OSAS) is a common disorder defined by repeated episodes of airflow cessation (apneas)leading to arterial hypoxemia and sleep disruption. OSAS has been associated with increased morbidity, mortality and diminished quality of life so far. This cross-sectional study aimed to assess the impact of OSAS on patients' Quality of Life, as measured by the Medical Outcomes Study Short Form-36 (SF-36).

PATIENTS AND METHODS

Two hundred and forty five subjects referred to the sleep laboratory and underwent full polysomnography overnight. Prior to sleep study onset, we registered height and weight, medical history, smoking habit, drug consumption. Afterwards, each patient completed the SF-36. Eighty subjects not diagnosed with sleep apnea [apnea hypopnea index (AHI < 5)] were excluded. Therefore, 165 subjects (121 male and 44 female) remained.

RESULTS AND CONCLUSIONS

Statistical analysis revealed that in patients with respiratory disturbance index (RDI) ≥ 15, (n = 115), RDI was independently associated with lower performance in role limitations due to physical problems (p = 0.005). Additionally, RDI was the only factor associated with decreased vitality (p = 0.014) and mental health scores (p = 0.047). In the same patient subgroup, body mass index (BMI) and age were associated with poorer scores in physical functioning (p < 0.001 and p = 0.003, respectively). BMI was an independent clinical predictor of worse scores in bodily pain (p = 0.006) general health (p = 0.006), social functioning (p = 0.025) and role limitations due to emotional problems (p = 0.004).

Infectious complications in patients with lung cancer

Infections remain a part of the natural course of cancer. During the course of their disease, patients with lung cancer frequently present with an infection that can ultimately be fatal. Pathogenesis of infectious syndromes is usually determined by the underlying disease, as well as, the iatrogenic manipulations that occur during its management. Hence, lung cancer infections include lower respiratory tract infections in the context of COPD, aspiration, obstruction and opportunistic infections due to immunosuppression. Moreover, treatment-related infectious syndromes including post operative pneumonia, febrile neutropenia and superimposed infection following radiation/chemotherapy toxicity is common. Importantly, diagnosis of infection in the febrile lung cancer patient is challenging and requires a high index of suspicion in order to distinguish from other causes of fever, including malignant disease and pulmonary embolism. Prompt initiation of treatment is pivotal to avoid increased mortality. Careful consideration of infection pathogenesis can predict most likely pathogens and guide antibiotic management, thus, ensuring most favourable outcome.

An unexpected pulmonary arterial aneurysm in a COPD patient

We present a case of an idiopathic pulmonary artery aneurysm in an asymptomatic patient who was treated for an irrelevant medical condition. Pulmonary artery aneurysms (PAA) are quite rare and can either be congenital or acquired. Congenital aneurysms are usually associated with cardiac malformations leading to pulmonary hypertension. Acquired aneurysms can be idiopathic or associated with infections (tuberculosis, syphilis), trauma, pulmonary valvular stenosis, or collagen diseases. Pulmonary artery aneurysms are not common and an idiopathic pulmonary artery aneurysm is a rare finding that could be diagnosed incidentally.

Association of ET-1 gene polymorphisms with COPD phenotypes in a Caucasian population

BACKGROUND AND AIM

The phenotypic expression of COPD consists of pulmonary emphysema and chronic bronchitis. An imprecise phenotypic definition may result in inconsistencies among genetic studies regarding COPD pathogenesis. Endothelin-1 gene polymorphisms have been linked to increased susceptibility of COPD development. The present study examined the involvement of +138 insA/delA and G198T ET-1 polymorphisms with emphysematous and bronchitic COPD phenotypes.

METHODS

In order to narrow down the phenotypic choices to either COPD-associated pulmonary emphysema or chronic bronchitis, a DLCO < 60% predicted threshold was chosen as an indicator of severe emphysema. 116 COPD smokers and 74 non-related, non-COPD smokers were evaluated.

RESULTS

Statistical analysis showed that the 4A allele of the +138insA/delA SNP and the 4A:T haplotype were associated predominantly with a chronic bronchitis phenotype, whereas the TT genotype of the G198T SNP was found to be protective from emphysema development.

CONCLUSIONS

The presence of both the 4A and T allele seems to modify the final expression of COPD towards a chronic bronchitis phenotype, since the G:3A haplotype was associated with a predominantly emphysematous phenotype in our study.

An unexpected pulmonary infection in a patient with gastric tube interposition, reconstruction of the hypopharynx and gastric-hypopharyngeal anastomosis

Pulmonary infection by Nocardia spp. has been recognized the last decades. Nocardia is an opportunistic pathogen in immunocompromised individuals; nevertheless, it has been recognized as an uncommon pathogen in immunocompetent patients. We report a case of pulmonary infection by Nocardia asteroides in an immunocompetent host who had a history of sulfate acid aspiration, followed by gastric tube interposition, reconstruction of the hypopharynx and gastric-hypopharyngial anastomosis.

Patients with gastroesophageal reflux disease and respiratory manifestations do not present lung function disorders during cardiopulmonary exercise test

Gastroesophageal reflux disease (GERD) has been associated with a variety of pulmonary manifestations, but it is unclear if gastroesophageal reflux causes any abnormality in pulmonary function. Cardiopulmonary exercise test (CPET) is a specialized method that is used to evaluate respiratory function during exercise. The aim of this study was to reveal any abnormality of pulmonary function in patients with GERD and respiratory symptoms. We evaluated 34 patients with GERD (24 men and 10 women, aged 21-63) and extraesophageal respiratory symptoms (wheezing and/or cough) before therapy and after a 12-week treatment with double dose of omeprazole. No patient presented abnormal spirometry. CPET was performed in all the patients at baseline and after completion of the 12-week treatment. CPET parameters including VO(2) rest, VO(2) max, VCO(2) rest, VCO(2) max, O(2)-puls rest, O(2)-puls max, HR (heart rate) rest, HRmax, PETCO(2) rest, PETCO(2) max, and VE/VCO(2) slope were recorded pretreatment and posttreatment. Twenty-four patients (70.6%) had esophagitis (grade A-D), 16 patients had hiatal hernia (47.1%), and 13 patients (38.2%) tested positive for Helicobacter pylori. All of the patients completed the CPET. No one presented shortness of breath or respiratory symptoms. CPET parameters were within normal limits in all of the patients. Twenty-eight patients were reevaluated. No improvement in any CPET parameter posttreatment was observed despite remission of esophageal and extraesophageal respiratory symptoms in all patients. No statistically significant difference was observed pretreatment and posttreatment between the patients older and younger than 40 years, smokers and nonsmokers, Hp(+) and Hp(-) patients, and those with and without hiatal hernia and esophagitis. The patients with GERD and respiratory manifestations and normal spirometry present no pulmonary dysfunction during CPET. No alterations in CPET values posttreatment or differences in CPET values according to age, smoking, Hp status, presence of esophagitis, or hiatal hernia were observed.

Endothelin-1 polymorphisms involved in impaired exercise tolerance in COPD patients. A pilot study

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide that may lead to impaired exercise tolerance. In this study we exhibit the relationship between two endothelin-1 (+134 3A/4A and G198T) SNPs involved in COPD and their association to impaired exercise tolerance.

MATERIALS AND METHODS

The study population consisted of 22 COPD smokers and 32 smoking controls which underwent pulmonary function tests to assess forced expiratory volume for 1 second (FEV1), forced vital capacity (FVC), as well as cardiopulmonary exercise testing. Single nucleotide polymorphism were isolated using Real-Time PCR.

RESULTS

The distribution of both genotypes (3A3A, 3A4A, 4A4A for the +134 3A/4A and GG, GT, TT for the G198T) did not different among patients and non-COPD smoking controls. Multivariate analysis showed that the 3A4A and GG genotypes in the COPD group were independently associated with better V'O2max values (Odd's Ratio (OR) = 12.5, 95% CI = -0.85-25.1, p = 0.049, and OR = 6.1, 95% CI = 0.83-11.4, p = 0.026, respectively). On the contrary analogous analysis in the non-COPD control group, showed that the 3A3A genotype was independently associated with increased V'O2/pulse (OR = 51.5, 95% CI = 17.2-85.7, p = 0.005) and the 3A4A genotype with increased DVE/DVCO2 value (OR = 3.8, 95% CI = -0.27-7.9, p = 0.054).

DISCUSSION

Our results show that endothelin-1 gene is implicated in exercise performance in COPD patients and might play a role in adaptation of the cardiopulmonary system to exercise.

Miliary pattern due to occupational lung disease in a patient with laryngeal cancer

Inhalation of metal dusts and fumes can induce a wide range of respiratory disorders, including granulomatosis, chemical pneumonitis and pulmonary interstitial disease. Laryngeal cancer is the most common cancer of the upper aerodigestive tract. We present a patient with occupational lung disease whose chest CT showed miliary nodular pattern, with concurrent laryngeal cancer who had been engaged in type printing for 22 years. Histology of the laryngeal lession showed squamous cell laryngeal cancer. Histology of the nodules showed a foreign body granulomatous response with several foreign body cells, most probably due to exposure to numerous inorganic (lanthanides, elements such us La, Ce, Nd, Sm, EU, Tb, Lu) and organic particles (such us acrylates, epoxy- and urethane-acrylates).

Determinants of specific sensitization in flour allergens in workers in bakeries with use of skin prick tests

Baker's asthma, like other forms of occupational asthma is probably the most serious manifestation of occupational allergy among bakery workers. It is caused by immunologic sensitization and subsequent allergic reactions in the airways to occupational specific airborne allergens. Skin Prick Tests (SPTs) play an important role in the diagnosis of baker's asthma and epidemiological field studies on frequencies of sensitization to flour. This paper presents a review of the available literature on prevalence of flours sensitization in bakery workers. Atopy and level of exposure appears to be a very strong determinant for sensitization to flour allergens. Prevention strategies and standard setting are discussed.

Basal metabolic rate is decreased in women with polycystic ovary syndrome and biochemical hyperandrogenemia and is associated with insulin resistance

OBJECTIVE

To evaluate basal metabolic rate (BMR) in women with PCOS and to determine its association with insulin resistance (IR).

DESIGN

Prospective assessment of BMR in women with PCOS.

SETTING

Outpatient clinic of the Division of Reproductive Endocrinology.

PATIENT(S)

The study included 91 Greek women with PCOS and biochemical hyperandrogenemia, with mean age 24.03 +/- 0.55 years and mean body mass index (BMI) 26.67 +/- 0.69 kg/m(2), and 48 matched regularly menstruating women, with mean age 26.33 +/- 0.93 years and mean BMI 23.35 +/- 0.85 kg/m(2), as control subjects.

INTERVENTION(S)

Assessment of BMR by indirect calorimetry, IR by HOMA and QUICKI indices, fasting insulin, and fasting glucose/insulin ratio.

MAIN OUTCOME MEASURE(S)

Reduced BMR in PCOS with or without IR.

RESULT(S)

Adjusted BMR was 1,868 +/- 41 kcal/day in the control group, 1,445.57 +/- 76 in all PCOS women, 1,590 +/- 130 in PCOS women without IR and 1,116 +/- 106 in PCOS women with IR. Adjusted BMR showed a statistically significant difference between women with PCOS and control subjects, with lowest values in the group of PCOS women with IR, even after adjusting all groups for age and BMI.

CONCLUSION(S)

Women with PCOS, particularly those with IR, present a significantly decreased BMR.

Hormonal responses to marathon running in non-elite athletes

BACKGROUND

Exercise is known to be a powerful stimulus for the endocrine system. The hormonal response to exercise is dependent on several factors including the intensity, duration, mode of exercise (endurance versus resistance), and training status of the subject. The aim of the present study was to determine the steroid hormonal response (immediately after a race and 1 week later) to endurance exercise under the real conditions of the classic Athens marathon in a group of well-trained, middle-aged, non-elite athletes.

METHODS

Blood samples were drawn 1 week before the race, directly after completion of the race, and 1 week later.

RESULTS

Serum cortisol and prolactin showed distinct rises 1 h after the race and returned to baseline 1 week later. Androstenedione and dehydroepiandrosterone sulphate did not show any changes. Total testosterone as well as free testosterone dropped significantly 1 h after the race but returned to baseline 1 week later.

CONCLUSION

In this particular group of non-elite, middle-aged marathon runners, the race resulted in an acute increase in serum cortisol and prolactin levels and in a concomitant decline in testosterone level. The aforementioned changes returned to baseline 1 week later.

Human genes in TB infection: their role in immune response

Tuberculosis (TB) caused by the human pathogen Mycobacterium tuberculosis, is the leading cause of morbidity and mortality caused by infectious agents worldwide. Recently, there has been an ongoing concern about the clarification of the role of specific human genes and their polymorphisms involved in TB infection. In the vast majority of individuals, innate immune pathways and T-helper 1 (Th1) cell mediated immunity are activated resulting in the lysis of the bacterium. Firstly, PTPN22 R620W polymorphism is involved in the response to cases of infection. The Arg753Gln polymorphism in TLR-2 leads to a weaker response against the M. tuberculosis. The gene of the vitamin D receptor (VDR) has a few polymorphisms (BsmI, ApaI, Taq1, FokI) whose mixed genotypes alter the immune response. Solute carrier family 11 member (SLC11A1) is a proton/divalent cation antiporter that is more familiar by its former name NRAMP1 (natural resistance associated macrophage protein 1) and can affect M. tuberculosis growth. Polymorphisms of cytokines such as IL-10, IL-6, IFN-g, TNF-a, TGF-b1 can affect the immune response in various ways. Finally, a major role is played by M. tuberculosis antigens and the Ras-associated small GTP-ase 33A. As far as we know this is the first review that collates all these polymorphisms in order to give a comprehensive image of the field, which is currently evolving.

Pulmonary complications in diabetes mellitus

Clear decrements in lung function have been reported in patients with diabetes over the past two decades, and many reports have suggested plausible pathophysiological mechanisms. However, there are no reports of functional limitations of activities of daily living ascribable to pulmonary disease in patients with diabetes. This review attempts to summarize the available information from the present literature, to describe the nature of the lung dysfunction in diabetes and the emerging clinical implications of such dysfunction.

Urinothorax: an unexpected cause of pleural effusion in a patient with non-Hodgkin lymphoma

Urinothorax is a rather rare cause of pleural effusion and its potential mechanism is urinary tract obstruction or trauma that results in urine leakage and accumulation inside the pleural space. Patients with non-Hodgkin lymphoma could present with pleural effusion due to mediastinal lymphadenopathy or extrathoracic manifestation such as urinary tract obstruction, the latter described in our case report. Physicians must be aware even of the more occult mechanisms of pleural fluid accumulations which could point to extrathoracic manifestations of involvement.

Does CPAP therapy improve erectile dysfunction in patients with obstructive sleep apnea syndrome?

OBJECTIVE

The aim of the study was to examine the quality of the characteristics of Erectile Dysfunction (ED) in men with Obstructive Sleep Apnea Syndrome (OSAS) and to investigate whether there is an improvement with the use of continuous positive airway pressure (CPAP) therapy.

MATERIALS AND METHODS

Fifteen men with OSAS and sexual dysfunction have been investigated in this follow-up study. The treatment period was for 12 weeks and the therapeutic CPAP levels were determined during the full night of the therapeutic titration.

RESULTS

In our 15 treated patients, the International Index Erectile Function (IIEF) total and all domain scores had increased after the CPAP treatment compared to the baseline, except for that of sexual desire domain.

CONCLUSIONS

CPAP therapy can improve the sexual function in ED patients with OSAS.

Sleep Apnea Syndrome in a Referral Population in Greece: Influence of Social Factors

OBJECTIVE

The aim of this work was to study whether social factors are risk factors for obstructive sleep apnea (OSA). A second objective was to investigate gender differences in relation to referral to a sleep laboratory for sleep-related breathing symptoms.

STUDY DESIGN

A retrospective cross-sectional study was conducted in the referral sleep disorders laboratory in the tertiary University Hospital in Patras in southwest Greece. A sample of 362 subjects originated from this geographic region was screened for social characteristics, i.e., marital status, occupation, and education.

RESULTS

The apnea hypopnea index (AHI) was approximately three times as high in men as in women (p < 0.05). Snoring was reported to be a symptom by 76.6% of males and 75% of females. Excessive daytime sleepiness (EDS) was reported by 25.5% of males and 15% of females. Arousals during sleep were reported by 5.7% of men and 10% of women. The ratio of subjects with concomitant disorders or symptoms did not differ between sexes (p > 0.05). The influence of age, body mass index (BMI), gender, smoking, and social characteristics on AHI was examined by multinomial logistic regression. The following factors remained independent risk factors for the presence of moderate to severe OSA (i.e., AHI > 15/h compared with AHI < 5): (1) Gender: the odds ratio (OR) of males to females was 6.23 (CI = 1.89-20.5). (2) Obesity: the OR of subjects with BMI >30.5 kg/m(2) in comparison to those with lower BMI was 3.83 (CI = 1.86-7.86). (3) Marital status: The OR of married subjects to singles was 2.30 (CI = 1.01-5.32). (4) Occupational status: The OR of subjects outside the work force was 3.85 (CI = 1.16-12.74) and that of the self-employed was 1.70 (CI = 0.70-4.10) compared to a reference group of clerks/employees.

CONCLUSION

In our study factors associated with the presence of sleep apnea include gender (men), obesity, marriage, and self-employment or being outside the work force.

Sildenafil versus continuous positive airway pressure for erectile dysfunction in men with obstructive sleep apnea: a comparative study of their efficacy and safety and the patient's satisfaction with treatment

AIM

To assess the efficacy of sildenafil and continuous positive airway pressure (CPAP) in the treatment of concurrent erectile dysfunction (ED) with obstructive sleep apnea (OSA), and to gauge the level of treatment satisfaction in patients and their partners.

METHODS

Forty men were treated for 12 weeks with sildenafil 100 mg (20 men) or CPAP during nighttime sleep (20 men). Treatment efficacy was assessed by the rate of successful intercourse attempts, and satisfaction with treatment was assessed by patients' and partners' answers to question 1 of the Erectile Dysfunction Inventory of Treatment Satisfaction.

RESULTS

Under sildenafil, 128 of 249 (51.4%) intercourse attempts were successful; under CPAP, 51 of 193 (26.9%) attempts were successful ((c)P < 0.001). Erectile function was improved in both groups. After sildenafil and CPAP treatment, the mean International Index for Erectile Function domain scores were 14.3 and 10.8, respectively ((b)P = 0.025), compared to 7.8 and 7 at baseline, respectively. CPAP and sildenafil were well tolerated. Sporadic episodes of nasal dryness under CPAP and transient headache and flushing under sildenafil were not significant. Fifty percent of patients treated with sildenafil and 25% with CPAP were satisfied with the treatment, and their partners were equally satisfied. The satisfaction scores for both patients and partners under sildenafil were superior to those under CPAP ((c)P < 0.002).

CONCLUSION

Both sildenafil 100 mg and CPAP, used separately, had positive therapeutic impact but sildenafil was superior. Patients and their partners were more satisfied with sildenafil for the treatment of ED. However, because of the high proportion of dissatisfied men and partners, new therapeutic agents or a combination of the two methods must be studied further.

Specific sensitization in wheat flour and contributing factors in traditional bakers

Skin prick tests (SPTs) play an important role in the diagnosis of bakers asthma and epidemiological field studies on frequencies of sensitization to wheat or rye flour. In many epidemiological studies the investigators have tried to reveal the determinants of specific sensitization, and atopy appears to be a very strong determinant for sensitization to flour allergens. Age and gender have not reported to be determinants of sensitization. Only one study found that sensitization in wheat flour with skin prick test was significantly associated with cigarette smoking. Few data are available on sensitization to wheat flour in populations without occupational exposure to bakery allergens. The aim of this study was to investigate the sensitization of wheat flour and other baking allergens (oat, barley, and rye flour) in traditional bakers and in cleaners in a big hospital in the same area. In addition the correlation of atopy with specific sensitization and the correlation of specific sensitization with age, sex, working hours, working years, smoking status and pack/years with use of skin prick tests.

Sildenafil combined with continuous positive airway pressure for treatment of erectile dysfunction in men with obstructive sleep apnea

OBJECTIVES

To assess efficacy and safety of the combination of sildenafil and continuous positive airway pressure (CPAP), and satisfaction with treatment for erectile dysfunction (ED) in men with obstructive sleep apnea (OSA).

PATIENTS AND METHODS

Forty men suffering from OSA and concurrent ED were treated with CPAP after a thorough investigation. After a 4-week run-in period, the patients were randomly allocated to treatment for 6 weeks; 20 men to the combination group, receiving additionally 100 mg sildenafil on demand for intercourse, and 20 men to CPAP alone. After a 1-week washout phase, the two groups switched to the other treatment arm for an additional 6 weeks period. End points for efficacy evaluation were the percentage of successful attempts for intercourse based on an event log and the overall satisfaction with sildenafil in the treatment of ED.

RESULTS

The patients recorded a total of 149 attempts for intercourse during the run-in phase with a success rate of 19.5%. During the 12 weeks of treatment, the success rate of intercourse attempts was 24.8% when only on CPAP and 61.1% when in combination with sildenafil (P < 0.001). Of the studied men, 70% were satisfied with the use of sildenafil while 30% remained unhappy with this additional treatment.

CONCLUSIONS

Sildenafil in combination with CPAP appears clearly superior to CPAP alone. The efficacy of this combination is superior to that of sildenafil alone, as reported in previous studies. Both treatment modalities are safe and well tolerated. However, approximately one-third of the patients remain unsatisfied even from the combination treatment. Further treatment options are needed.

The impact of long-term conventional treatment for overlap syndrome (obstructive sleep apnea and chronic obstructive pulmonary disease) on concurrent erectile dysfunction

PURPOSE

To assess the improvement of concurrent erectile dysfunction (ED) in men with overlap syndrome (obstructive sleep apnea and chronic obstructive pulmonary disease), treated with continuous positive airway pressure (CPAP) and bronchodilators.

MATERIAL AND METHODS

We evaluated 48 men of a mean age of 52.8+/-10 years suffering from both obstructive sleep apnea (OSA) and chronic obstructive pulmonary disease (COPD), and concurrent ED. They were treated with conventional for pulmonary obstruction therapy (CPAP and bronchodilators) for 6 months and then their erectile function (EF) status was reassessed. ED was considered as improved, if ED intensity score increased for at least five points compared to that of baseline. The determinants for improvement of ED were also evaluated, as well as patient's personal degree of satisfaction with the treatment they received as far as the disorder was concerned.

RESULTS

EF was improved in 12 patients (25%), but only two thirds of them were satisfied with the grade of improvement after treatment. ED improvement was related positively with age and apnea/hypopnea index and negatively with ED duration. ED intensity score, O(2) saturation at night and BMI were not significantly related to the outcome of EF improvement.

CONCLUSIONS

Conventional treatment for OSA and COPD, has a positive effect on concurrent ED on the minority of patients. This effect is possibly due to the improvement of respiration during sleep with CPAP and of oxygenation with bronchodilators continuously. Of the improved men, one third was not satisfied with the impact of this treatment modality on their EF. It is likely that specific for ED treatment is needed in these individuals.

The metabolic aspects and hormonal derangements in obstructive sleep apnoea syndrome and the role of CPAP therapy

Obstructive sleep apnea syndrome (OSAS) is part of a metabolic syndrome, whose main aspects are obesity, hypertension and diabetes, already incriminated for cardiovascular events. The evaluation of the effect of OSAS on the hormonal profile of patients shows a number of complex interactions that preclude the exact role of this syndrome among the numerous derangements on hormone levels as well as the effect of continuous positive airway pressure treatment, since many of the changes are known to occur with obesity as well. The clarification of the exact role and the mechanisms underlying these changes will help to stratify the cardiovascular and other health risks of this syndrome as well as the better application of CPAP therapy.

Obstructive sleep apnoea syndrome and genes

Obstructive sleep apnoea (OSA) is a complex disease entity strongly influenced by genetic factors, especially those that affect obesity and fat distribution, upper airway muscle tone, craniofacial morphology, ventilatory control and sleep, giving rise to the OSA phenotype. OSA can also be considered a metabolic syndrome which adversely affects multiple organ systems, especially the cardiovascular system and the brain. The most widely used clinical marker for the diagnosis of OSA is the apnoea-hypopnoea index, calculated by polysomnography. A percentage of 35 to 40% of its variance can be attributed to genetic factors. Therefore, the identification and elucidation of the genes implicated in the pathogenesis of OSA becomes a matter of extensive research and could lead to the development of therapeutic agents that can have a beneficial effect on the natural course of OSA.

Carcinoid tumour behind bronchiectasis

This report describes a female patient with bronchiectasis, presented to our department with recurrent hemoptysis. Bronchoscopy revealed nothing else but blood arising from the upper lobe bronchus. High resolution computing tomography of the lung (HRCT) revealed bronchiectasis of the upper lobe. A right upper lobectomy was performed. Behind bronchiectasis multiple nodular lesions, 5-10 mm were observed. Histological and immunohistochemical examination revealed findings consistent with peripheral typical bronchial carcinoids.

Recurrent catamenial hemothorax

Endometriosis is a common cause of chronic pelvic pain and infertility affecting women of reproductive age, but the disease in rare conditions may be extragenital so may be present with a variety of symptoms. This is a report of an unusual case of pelvic endometriosis that presented with a recurrent hemothorax.

An unusual presentation of tuberculosis

We describe a case of a male with no symptoms and normal chest X ray, diagnosed with TB. The chest computed tomography revealed a cavity formation on the upper left lobe.

Erectile dysfunction in men with obstructive sleep apnea syndrome: a randomized study of the efficacy of sildenafil and continuous positive airway pressure

The aim of this study was to compare the efficacy of sildenafil and continuous positive airway pressure (CPAP) in men with erectile dysfunction (ED) and obstructive sleep apnea syndrome (OSAS). In all, 30 men were randomly treated for 12 weeks either with sildenafil 100 mg before intercourse (15 men) or CPAP during night time sleep (15 men). Under sildenafil, 97/180 (53.9%) of attempted intercourses were successful compared to 33/138 (23.9%) under CPAP. The mean IIEF (erectile function domain score) was 12.9 and 9.3 after sildenafil and CPAP treatment, respectively (P=0.007), compared to 7.9 and 7 at baseline. In all, 53.3% of patients were satisfied with sildenafil and 20% with CPAP for ED treatment (P=0.058). Although sildenafil was superior to CPAP, comorbidities and OSAS per se possibly resulted in a lower effectiveness of sildenafil compared to that in the general population of ED men. While about half of the patients were not satisfied even with the more effective treatment, we conclude that a combination of the two therapeutic tools or a different therapeutic mode should be studied further.