Skewed X-chromosome inactivation drives the proportion of DNAAF6-defective airway motile cilia and variable expressivity in primary ciliary dyskinesia

BACKGROUND

Primary ciliary dyskinesia (PCD) is a rare airway disorder caused by defective motile cilia. Only male patients have been reported with pathogenic mutations in X-linked DNAAF6, which result in the absence of ciliary dynein arms, whereas their heterozygous mothers are supposedly healthy. Our objective was to assess the possible clinical and ciliary consequences of X-chromosome inactivation (XCI) in these mothers.

METHODS

XCI patterns of six mothers of male patients with DNAAF6-related PCD were determined by DNA-methylation studies and compared with their clinical phenotype (6/6 mothers), as well as their ciliary phenotype (4/6 mothers), as assessed by immunofluorescence and high-speed videomicroscopy analyses. The mutated X chromosome was tracked to assess the percentage of cells with a normal inactivated DNAAF6 allele.

RESULTS

The mothers' phenotypes ranged from absence of symptoms to mild/moderate or severe airway phenotypes, closely reflecting their XCI pattern. Analyses of the symptomatic mothers' airway ciliated cells revealed the coexistence of normal cells and cells with immotile cilia lacking dynein arms, whose ratio closely mirrored their XCI pattern.

CONCLUSION

This study highlights the importance of searching for heterozygous pathogenic DNAAF6 mutations in all female relatives of male PCD patients with a DNAAF6 defect, as well as in females consulting for mild chronic respiratory symptoms. Our results also demonstrate that about one-third-ranging from 20% to 50%-normal ciliated airway cells sufficed to avoid severe PCD, a result paving the way for gene therapy.

Use of Patient-Reported Symptom Data in Clinical Decision Rules for Predicting Influenza in a Telemedicine Setting

INTRODUCTION

Increased use of telemedicine could potentially streamline influenza diagnosis and reduce transmission. However, telemedicine diagnoses are dependent on accurate symptom reporting by patients. If patients disagree with clinicians on symptoms, previously derived diagnostic rules may be inaccurate.

METHODS

We performed a secondary data analysis of a prospective, nonrandomized cohort study at a university student health center. Patients who reported an upper respiratory complaint were required to report symptoms, and their clinician was required to report the same list of symptoms. We examined the performance of 5 previously developed clinical decision rules (CDRs) for influenza on both symptom reports. These predictions were compared against PCR diagnoses. We analyzed the agreement between symptom reports, and we built new predictive models using both sets of data.

RESULTS

CDR performance was always lower for the patient-reported symptom data, compared with clinician-reported symptom data. CDRs often resulted in different predictions for the same individual, driven by disagreement in symptom reporting. We were able to fit new models to the patient-reported data, which performed slightly worse than previously derived CDRs. These models and models built on clinician-reported data both suffered from calibration issues.

DISCUSSION

Patients and clinicians frequently disagree about symptom presence, which leads to reduced accuracy when CDRs built with clinician data are applied to patient-reported symptoms. Predictive models using patient-reported symptom data performed worse than models using clinician-reported data and prior results in the literature. However, the differences are minor, and developing new models with more data may be possible.

[Use of antibiotics, in a pediatric hospital, for respiratory infection and diarrheal disease]

Background

The World Health Organization (WHO) reports an increasing unjustified use of antibiotics in the treatment of Acute Respiratory Infections (ARI) and Acute Diarrheal Diseases (ADD) in children under five years of age. This has generated problems such as polypharmacy and the inappropriate use of antibiotics; characterized by incorrect dosage, use in viral infections, prescription inconsistent with clinical guidelines.

Objective

To analyze the prescription of antibiotics, their diagnostic-therapeutic congruence, as well as the correct filling of the medical prescription, in a tertiary level hospital in Mexico.

Material and methods

Observational, descriptive cross-sectional study. The electronic medical prescriptions made during the period January-December 2017 with a clinical diagnosis of ARI and EDA were analyzed.

Results

Of a total of 21,446 boys and girls under five years of age, 10,233 prescriptions were issued for the treatment of ARI and ADD diagnoses. 80% of the prescriptions complied with the items indicated in the electronic file.

Conclusions

The prescription of antibiotics showed a prudent use of antibiotics both in the management of acute diarrheal diseases and in the management of acute respiratory diseases. Diagnostic-therapeutic congruence was found in most of the cases in the prescriptions analyzed.

A scoping review of mHealth monitoring of pediatric bronchial asthma before and during COVID-19 pandemic

Mobile (m) Health technology is well-suited for Remote Patient Monitoring (RPM) in a patient's habitual environment. In recent years there have been fast-paced developments in mHealth-enabled pediatric RPM, especially during the COVID-19 pandemic, necessitating evidence synthesis. To this end, we conducted a scoping review of clinical trials that had utilized mHealth-enabled RPM of pediatric asthma. MEDLINE, Embase and Web of Science were searched from September 1, 2016 through August 31, 2021. Our scoping review identified 25 publications that utilized synchronous and asynchronous mHealth-enabled RPM in pediatric asthma, either involving mobile applications or via individual devices. The last three years has seen the development of evidence-based, multidisciplinary, and participatory mHealth interventions. The quality of the studies has been improving, such that 40% of included study reports were randomized controlled trials. In conclusion, there exists high-quality evidence on mHealth-enabled RPM in pediatric asthma, warranting future systematic reviews and/or meta-analyses of the benefits of such RPM.

[Practical guide for the follow-up and management of patients with severe asthma treated with biologics]

The management of severe uncontrolled asthma with biologics is an area of extreme difficulty given the scarcity of information regarding their starting criteria, the variables to be evaluated to determine the efficacy and safety of their management, the cut-off points to determine the timing to change or add another biological and the process to decrease or withdraw steroids. This review incorporates the latest information and makes a proposal based on it.

[Coinfections by SARS-CoV-2 and other respiratory viruses and their clinical outcome]

BACKGROUND

SARS-CoV-2 is a coronavirus described for the first time in China, in December 2019. This virus can cause a disease with a very variable spectrum that ranges from asymptomatic cases to deaths. The most severe cases are normally associated with comorbidities and with the age of the patient. However, there are patients who are not part of these risk groups and develop severe cases.

OBJETIVE

To determine the association between coinfections by SARS-CoV-2 and other respiratory viruses and their clincal outcome.

MATERIAL AND METHODS

RT-qPCR was performed to determine the presence of 16 respiratory viruses in 103 confirmed COVID-19 cases. Demographic and comorbid data were collected, and statistical analyzes were performed to determine associations with severity.

RESULTS

Of the 103 analyzed cases, 14 (13.6%) presented a coinfection, of these, 92% did not require hospitalization, even in those cases in which the patient presented advanced age and some comorbidities.

CONCLUSIONS

These results suggest that coinfection of SARS-CoV-2 and other respiratory viruses is not related to a more severe form of COVID-19 and, in some cases, depending on the virus involved, it could even lead to a better prognosis. These findings lay the foundations for the development of new studies that could determine the biological mechanism of this phenomenon.

Health professionals' perceptions of palliative care for end-stage cardiac and respiratory conditions: a qualitative interview study

BACKGROUND

End-stage cardiac and respiratory diseases are common in the UK. People with these end-stage conditions experience similar, or even worse, symptomatic suffering to cancer patients but are less likely to receive specialist palliative care services. The objective of this study is to explore health professional perceptions and current practices in relation to specialist palliative care for patients with end-stage cardiac and respiratory disease.

METHODS

Qualitative study using in-depth interviews with health professionals, audio recorded and transcribed verbatim for thematic analysis. The study was conducted with doctors and nurses from cardiology, respiratory, and palliative care specialities in the UK. The participants had to be involved clinically in providing care to people with end-stage cardiac or respiratory diseases.

RESULTS

A total of 16 health professionals participated (5 cardiology, 5 respiratory, and 6 palliative care). Participants reported variable disease trajectories in these diseases making deciding on timing of palliative care involvement difficult. This was complicated by lack of advance care planning discussions, attributed to poor communication, and lack of health professional time and confidence. Participants reported poor interdepartmental education and limited specialist palliative care involvement in multidisciplinary teams.

CONCLUSIONS

Palliative care for end-stage cardiac and respiratory diseases needs more attention in research and practice. Better integration of advance care planning discussions and early patient education/professional awareness are needed to enable timely referral to palliative care. Moreover, increased interdepartmental working for health professionals via joint educational and clinical meetings is perceived as likely to support earlier and increased referral to specialist palliative care services.

Observational study of therapeutic bronchoscopy in critical hypoxaemic ventilated patients with COVID-19 at Mediclinic Midstream Private Hospital in Pretoria, South Africa

Background

Flexible fibreoptic bronchoscopy (FFB) has been used for years as a diagnostic and therapeutic adjunct for the diagnosis of potential airway obstruction as a cause of acute respiratory failure or in the management of hypoxaemia ventilated patients. In these circumstances, it is useful to evaluate airway patency or airway damage and for the management of atelectasis.

Objectives

To evaluate the use of FFB as a rescue therapy in mechanically ventilated patients with severe hypoxaemic respiratory failure caused by COVID-19.

Methods

We enrolled 14 patients with severe and laboratory confirmed COVID-19 who were admitted at Mediclinic Midstream Private Hospital intensive care unit in Pretoria, South Africa, in July 2020.

Results

FFB demonstrated the presence of extensive mucus plugging in 64% (n=9/14) of patients after an average of 7.7 days of mechanical ventilation. Oxygenation improved significantly in these patients following FFB despite profound procedural hypoxaemia.

Conclusion

Patients with severe COVID-19 pneumonia who have persistent hypoxaemia despite the resolution of inflammatory parameters may respond to FFB with removal of mucus plugs. We propose consideration of an additional pathophysiological acute phenotype of respiratory failure, the mucus type (M-type).

[COVID-19 and Pulmonology: New Challenges and Opportunities]

N/a.

[TTV, what is it and what do we know in Mexico?]

The aim of this editorial is to present a brief description of the Torque teno virus’ epidemiology and establish the actuality of their study in México. Also, we mentioned the studies made in México and Yucatán, specifically in the Center of Regional Research “Dr. Hideyo Noguchi” of the Autonomous University of Yucatán.

Effectiveness of Healthcare Coordination in Patients with Chronic Respiratory Diseases

Coordination of healthcare effectively prevents exacerbations and reduces the number of hospitalizations, emergency visits, and the mortality rate in patients with chronic respiratory diseases. The purpose of this study was to determine clinical effectiveness of ambulatory healthcare coordination in chronic respiratory patients and its effect on the level of healthcare services as an indicator of direct medical costs. We conducted a retrospective health record survey, using an online database of 550 patients with chronic respiratory diseases. There were decreases in breathing rate, heart rate, and the number of cigarettes smoked per day, and forced vital capacity (FVC) and forced expired volume in 1 s (FEV1) increased after the implementation of the coordinated healthcare structure. These benefits were accompanied by increases in the number of visits to the pulmonary outpatient clinic (p < 0.001), diagnostic costs (p < 0.001), and referrals to other outpatient clinics (p < 0.003) and hospitals (p < 0.001). The advantageous effects of healthcare coordination on clinical status of respiratory patients above outlined persisted over a 3-year period being reviewed.

Air pollution and cardiovascular and respiratory disease: Rationale and methodology of CAPACITY study

BACKGROUND

Considering the high level of air pollution and its impact on health, we aimed to study the correlation of air pollution with hospitalization and mortality of cardiovascular (CVD) and respiratory diseases (ResD) (CAPACITY) to determine the effects of air pollutants on CVD and ResD hospitalizations and deaths in Isfahan, Iran.

METHODS

Hourly levels of air pollutants including particulate matter (PM), carbon monoxide (CO), nitrogen dioxide (NO2), sulfur dioxide (SO2), and ozone (O3), information of CVD and ResD admissions and death certificate were obtained respectively from Department of Environment (DOE), Iran, hospitals and cemetery. Time series and case-crossover model were used to find the impact of air pollutants. This paper only summarizes the descriptive findings of the CAPACITY study.

RESULTS

The total number of hospitalized patients were 23781 in 2010 and 22485 in 2011. The most frequent cause of hospitalization and death was ischemic heart diseases in both years. While the mean annual levels of O3, CO, and PM10 were lower in 2011 than in 2010, NO2 and SO2 levels higher in 2011. In both years, PM10 was similarly increased during last month of fall, late spring and early summer. In 2011, the PM2.5 and PM10 monthly trend of change were similar.

CONCLUSION

The CAPACITY study is one of the few large-scale studies that evaluated the effects of air pollutants on a variety of CVD and ResD in a large city of Iran. This study can provide many findings that could clarify the effects of these pollutants on the incidence and burden of both disease groups.

Throat swabs have no influence on the management of patients with sore throats

BACKGROUND

Throat swabs are neither specific nor sensitive for micro-bacteria causing sore throat symptoms; however, current guidelines suggest they are still useful in some cases.

METHOD

Retrospective and prospective analyses were conducted of throat swabs requested within the months of January 2016 and August 2016, respectively.

RESULTS

The study comprised 247 patients. Fifty-nine (24 per cent) had a positive culture. Forty-six grew group A beta-haemolytic streptococci, with the remainder growing candida (n = 10), coliform (n = 1) and klebsiella (n = 2). There was no significant difference in culture rates between primary or secondary care sources (χ2 = 0.56, p = 0.45). None of the swabs influenced a variation in patient management from local antimicrobial policies. Current practice has an estimated annual financial impact of £3 434 340 on the National Health Service.

CONCLUSION

Throat swabs do not influence the antimicrobial treatment for patients with sore throats, even under current guidelines, and incur unnecessary cost. Current clinical guidelines could be reviewed to reduce the number of throat swabs being conducted unnecessarily.

Obstructive Sleep Apnea: Preoperative Screening and Postoperative Care

The incidence of obstructive sleep apnea (OSA) has reached epidemic proportions, and it is an often unrecognized cause of perioperative morbidity and mortality. Profound hypoxic injury from apnea during the postoperative period is often misdiagnosed as cardiac arrest due to other causes. Almost a quarter of patients entering a hospital for elective surgery have OSA, and >80% of these cases are undiagnosed at the time of surgery. The perioperative period puts patients at high risk of apneic episodes because of drug effects from sedatives, narcotics, and general anesthesia, as well as from the effects of postoperative rapid eye movement sleep changes and postoperative positioning in the hospital bed. For adults, preoperative screening using the STOP or STOP-Bang questionnaires can help to identify adult patients at increased risk of OSA. In the pediatric setting, a question about snoring should be part of every preoperative examination. For patients with known OSA, continuous positive airway pressure should be continued postoperatively. Continuous pulse oximetry monitoring with an alarm system can help to prevent apneic catastrophes caused by OSA in the postoperative period.

Performance of rapid SOFIA Influenza A+B test compared to Luminex x-TAG respiratory viral panel assay in the diagnosis of influenza A, B, and subtype H3

Influenza is an acute respiratory illness caused by influenza A or B viruses that occur in outbreaks, mainly during the winter season. Rapid laboratory diagnosis of influenza can help guide the clinical management of suspected patients effectively. Clinical sensitivities and specificities of the rapid influenza diagnostic tests have varied considerably in the literature. Most of these studies are evaluated using previously frozen or stored specimens that had previously tested positive. This study compares the performance of the rapid SOFIA Influenza A+B test to nucleic acid multiplex test x-TAG respiratory viral panel (RVP) assay in freshly collected nasal aspirates and measured simultaneously by both assays. Retrospective data from 1649 nasal aspirates (September 2014 to May 2015) collected from adults as well as from children tested simultaneously by both rapid SOFIA Influenza A+B FIA immunofluorescence (Quidel, San Diego, CA) and qualitative nucleic acid multiplex RVP assay X-TAG Luminex technology (Luminex, Austin, Texas, USA) were analyzed. Concordance, and analytical sensitivity and specificity were evaluated for influenza A, subtypes H1 and H3, and influenza B. Prevalence for influenza A by RVP was 15%, for subtype H3 it was 11.2%, and for influenza B, 2.9%. None of the aspirates were positive for influenza A subtype H1. SOFIA Influenza rapid test demonstrated good specificity and low sensitivity compared with a nucleic acid test for influenza A, subtype H3, and for influenza B. SOFIA Influenza A + B test performed well in providing a rapid diagnosis, however, confirmatory molecular testing is recommended for negative test results. Re-evaluation of test performance should be periodically carried out during outbreaks with the emergence and circulation of new influenza strains.

Caffeine consumption and exacerbations of chronic obstructive pulmonary disease: retrospective study

BACKGROUND

The modulation of adenosine receptors has been proposed as new therapeutic target for chronic obstructive pulmonary disease, but studies in humans were negative. Caffeine is widely consumed and acts by non-selective modulation of these receptors, allowing for a non-interventional evaluation of the purinergic effects on COPD. We evaluated the effects of chronic caffeine consumption on the risk for COPD exacerbations.

METHODS

Retrospective study including patients with COPD. The total number of exacerbations during a three-year period and the mean daily caffeine consumption in the last twenty years were evaluated. A univariate and multiple regression analysis were performed for evaluation of the significant predictors of exacerbations.

RESULTS

A total of 90 patients were included. Most were males (82.2%) and had a mean forced expiratory volume in the first second (FEV1) of 57.0±17.1% predicted. The mean daily caffeine consumption was 149.7±140.9mg. There was no correlation between the mean caffeine consumption and exacerbations (p>0.05).

DISCUSSION

Our results suggest that caffeine has no significant effect on the frequency of COPD exacerbations. These conclusions are limited by the sample size and the retrospective nature of the study.

Unrecognized heart failure and chronic obstructive pulmonary disease (COPD) in frail elderly detected through a near-home targeted screening strategy

BACKGROUND

Reduced exercise tolerance and dyspnea are common in older people, and heart failure (HF) and chronic obstructive pulmonary disease (COPD) are the main causes. We want to determine the prevalence of previously unrecognized HF, COPD, and other chronic diseases in frail older people using a near-home targeted screening strategy.

METHODS

Community-dwelling frail persons aged ≥65 years underwent a 2-step screening strategy. First, they received a questionnaire inquiring about dyspnea and exercise tolerance. Those with exercise intolerance and/or dyspnea were invited to visit their primary care physician's office for a screening program, including medical history taking, physical examination, blood tests, electrocardiography, spirometry, and echocardiography. The final diagnosis of every patient was determined by a panel consisting of 3 physicians.

RESULTS

Of the 570 elderly who filled out the questionnaire, 395 (69%) had reduced exercise tolerance or dyspnea. Of these, 389 underwent the screening program: 127 (33.5%, 95% confidence interval, 28.9-38.4%) were newly diagnosed with HF (mainly HF with a preserved ejection fraction [23.5%]), and previously unrecognized COPD was detected in 16.8% (95% confidence interval, 13.4-20.9%). In total, 165 patients (43.9%) received a new diagnosis of either HF, COPD, or both. Other new diagnoses (in 32.7% of the screening program patients) included atrial fibrillation (1.8%), valvular disease (21.4%), (persisting) asthma (3.1%), anemia (12.7%), and thyroid disease (0.6%). No clear explanation for the complaints of 47 patients (12.2%) was found using our strategy.

CONCLUSION

Unrecognized chronic diseases might be detected in community-dwelling frail elderly using a near-home screening strategy that is simple to implement. It remains to be proven, however, whether optimizing treatment of the newly detected diagnoses in this fragile population with multimorbidities and polypharmacy improves quality of life and reduces morbidity and mortality.

Advances in diagnosis and treatment of latent tuberculosis infection

In the United States, latent tuberculosis infection (LTBI) affects between 10 and 15 million people, of whom 10% may develop active tuberculosis disease. People at increased risk for tuberculosis reactivation include recent immigrants from countries with a high incidence of tuberculosis, children younger than age 5, people who have been infected with Mycobacterium tuberculosis within the past 2 years, or people with immunosuppression for a variety of reasons. Appropriate diagnosis and treatment of LTBI are critical for controlling and eventually eliminating tuberculosis as a public health problem. Although the tuberculin skin test is the traditional diagnostic measure for LTBI, reduced specificity has promoted the development and utilization of the interferon-γ release assays as an in vitro blood test with specific antigens to M. tuberculosis (QuantiFERON-TB Gold In-Tube test and the T.SPOT-TB test are commercially available). Despite the rise of the new diagnostic tests, however, there is still no gold standard for diagnosing LTBI, and epidemiologic risks and comorbidities need to be taken into account before initiating therapy. Current diagnostic tests combined with recommended treatment regimens are valuable tools that, when used correctly, promise to hurry the elimination of tuberculosis.

Workers' compensation for occupational respiratory diseases

The respiratory system is one of the most important body systems particularly from the viewpoint of occupational medicine because it is the major route of occupational exposure. In 2013, there were significant changes in the specific criteria for the recognition of occupational diseases, which were established by the Enforcement Decree of the Industrial Accident Compensation Insurance Act (IACIA). In this article, the authors deal with the former criteria, implications of the revision, and changes in the specific criteria in Korea by focusing on the 2013 amendment to the IACIA. Before the 2013 amendment to the IACIA, occupational respiratory disease was not a category because the previous criteria were based on specific hazardous agents and their health effects. Workers as well as clinicians were not familiar with the agent-based criteria. To improve these criteria, a system-based structure was added. Through these changes, in the current criteria, 33 types of agents and 11 types of respiratory diseases are listed under diseases of the respiratory system. In the current criteria, there are no concrete guidelines for evaluating work-relatedness, such as estimating the exposure level, latent period, and detailed examination methods. The results of further studies can support the formulation of detailed criteria.

Hand hygiene and face touching in family medicine offices: a Cincinnati Area Research and Improvement Group (CARInG) network study

BACKGROUND

Family medicine offices may play an important role in the transmission of common illnesses such as upper respiratory tract infections (URTIs). There has, however, been little study of whether physicians teach patients about URTI transmission and what their own actions are to prevent infection. The purpose of this study was to assess the quality of hand hygiene and the frequency with which family physicians and staff touch their eyes, nose, and mouth (the T-zone) as well as physician and staff self-reported behaviors and recommendations given to patients regarding URTI prevention.

METHODS

We observed family physicians and staff at 7 offices of the Cincinnati Area Research and Improvement Group (CARInG) practice-based research network for the quality of hand hygiene and number of T-zone touches. After observations, participants completed surveys about personal habits and recommendations given to patients to prevent URTIs.

RESULTS

A total of 31 clinicians and 48 staff participated. They touched their T-zones a mean of 19 times in 2 hours (range, 0-105 times); clinicians did so significantly less often than staff (P < .001). We observed 123 episodes of hand washing and 288 uses of alcohol-based cleanser. Only 11 hand washings (9%) met Centers for Disease Control and Prevention criteria for effective hand washing. Alcohol cleansers were used more appropriately, with 243 (84%) meeting ideal use. Participants who were observed using better hand hygiene and who touched their T-zone less report the same personal habits and recommendations to patients as those with poorer URTI prevention hygiene.

CONCLUSIONS

Clinicians and staff in family medicine offices frequently touch their T-zone and demonstrate mixed quality of hand cleansing. Participants' self-rated URTI prevention behaviors were not associated with how well they actually perform hand hygiene and how often they touch their T-zone. The relationship between self-reported and observed behaviors and URTIs in family medicine office settings needs further study.