Pulmonary & Respiratory Medicine

We report a 45 year old male with right sided pleural mesothelioma who received neoadjuvant chemotherapy prior to a right extrapleural pneumonectomy followed by adjuvant chemotherapy. The patient became tumor free and remained in remission for 19 months following which he developed a lymphangitic spread over the contralateral lung. His diagnosis was confirmed by a bronchoscopic transbronchial biopsy of the left lung. The patient died from progressive respiratory failure over a period of three months. Such a relapse with an aggressive and fatal lymphangitic spread is rarely seen and reported in malignant pleural mesothelioma. Discussion and review of the literature are provided. Mesothelioma is still considered, worldwide, a rare cancer of the serosal membranes. It typically involves the pleural cavity but other reported sites include the peritoneum, pericardium and Tunica vaginalis of the testis. The usual progression of the mesothelioma is coalescence of multiple, small nodules into large masses that invade, entrap and destroy the affected organ by direct extension and invasion. We report an unusual case of relapsing mesothelioma, recurring in an aggressive and fatal form, after 19 months of remission.

Obesity is an increasingly frequent condition associated with increased adipose, systemic and pulmonary inflammation. There is an emerging and unexpected finding that obese individuals may not be at a greater risk for ARDS and, indeed, may even be partially protected against ARDS. This finding is known as the Obesity-ARDS Paradox. In this review we discuss the observations regarding this intriguing phenomenon and begin to elaborate on the theoretical rationale that obesity-triggered low-grade inflammatory processes may constitute pre-conditioning insults or trigger anti-inflammatory adaptive mechanisms that confer protection against ARDS.

Lung transplantation is a therapeutic option for selected patients with severe interstitial disease who continue to have progressive clinical deterioration. There is a survival advantage for selected patients who undergo transplant, but it primarily improves quality of life after transplantation. Unfortunately, patients with IPF have worse outcomes following lung transplantation due to various factors. This review article will describe several common postoperative complications including an astamotic complications, allograft dysfunction, cardiovascular complications, thromboembolic phenomenon, renal failure, neurologic complications and complications related to the native lung in the single lung transplant recipients.

Background and Objectives: Asthma is one of the chronic respiratory diseases affecting both genders and all ages across the globe. The treatment and control of asthma imposes significant economic burden on patients as well as the healthcare system. Patients also report absenteeism from school/work and poor quality of life. There are very few studies evaluating the cost of asthma in UAE. The objective of this study is to evaluate the cost of asthma in Dubai region of United Arab Emirates.

Material and Methods: Asthma prevalence and unit cost estimates were applied to the population of Dubai aged 5 years and above, based on the figures from the Dubai Statistic Center 2009 census. The asthma treatment profiles of the patients in Dubai as well as the days absent from school/work and quality of life data were obtained from the Asthma Insights and Reality for the Gulf and Near East (AIRGNE) study. The cost of drugs was procured from the purchase department of Dubai Health Authority (DHA) and cost of out-patient visits as well as hospital stay and emergency visits was also provided by the DHA. The cost of asthma in this study is the direct cost of drugs, hospital stay and visits as out-patient and ER visits, along with supplementary costs in terms of days lost from work or school.

Results: The total direct cost of asthma in Dubai was about 88 million Dirhams (AED 87,917,202). The maximum contribution to this was from expenditure on out-patient visits (37% - AED 32,217,143), followed by that on hospital stays (23% - AED 23,587,008). The cost on medication and ER visits represented 20% and 16% of the direct cost respectively. Absenteeism from school was reported by 50% of asthmatic children, asthmatics also reported an average loss of 4 days of work per year due to asthma.

Conclusion: There is a huge economic burden on the patients and healthcare services due to asthma. Taking into account the considerable expenditure on the out-patient visits, ER visits and hospital stay, efforts must be directed towards improved asthma control and patient education about their disease.

Background: Forced Vital Capacity (FVC) has been used to assess respiratory muscle strength in patients with Neuromuscular Disease (NMD). However, postural changes to FVC have not been assessed in relation to the start of Non-Invasive Ventilation (NIV). This study aims to assess the changes to postural FVC for indications of NIV.

Methods: The records of spirometry performed in seated and supine posture were retrospectively reviewed in 33 patients with NMD [18 breathing spontaneously (SB), 15 receiving NIV]. The change in FVC (in L) between seated (sit) and supine (sup) positions was expressed as %⊗ FVC (sit – sup) = [{FVC(L)sit – FVC(L)sup}/FVC(L)sit]. The postural change in forced expiratory flow (FEF), % FEF (sit – sup) was similarly computed.

Results: %ΔFVC (sit – sup) in patients receiving NIV exceeded the %ΔFVC (sit – sup) of SB patients by 14-fold (p = 0.001). %ΔFEF (sit–sup) however, did not reach statistical significance between cohorts. There was a negative correlation between %ΔFVC (sit-sup) and FVCsit(% pred) (R = -0.40, p = 0.02), and a direct correlation between %ΔFVC(sit-sup) and %ΔFEF(sit-sup) (R = 0.72, p<0.0001) amongst all patients.

Conclusions: Postural change of FVC in patients with neuromuscular disease placed on noninvasive ventilation is significantly greater than in those still able to breathe spontaneously. A prospective longitudinal study designed to assess the predictive value of ΔFVC (sit – sup), and if possible, a threshold value for initiating NIV may provide a guideline more precise than the seated FVC.