Pulmonary & Respiratory Medicine

Objective: Resident doctors are required to gain skills in reading chest X-rays. There have been few studies regarding the effectiveness of resident education in reading chest X-ray. Here, we examined the effectiveness of an educational method we developed for radiographic interpretation. Methods: A standardized lecture about diagnosis of pneumonia on chest X-ray was developed in 2012 and given to all first-year postgraduate (PGY1) residents at St Luke’s International Hospital in Japan. The examination was composed of 30 chest X-ray images representing either no disease or pneumonia. For pneumonia films, respondents identify disease location from a choice of 6 answers (right upper lobe, right middle lobe, right lower lobe, left upper segment, left lingular segment and left lower lobe). Total scores were compared before and after the intervention, and again 1 year later. Results: Twenty-one residents completed the 1-year follow-up exam. The overall percentage of correct answers for pre-lecture, post-lecture, and 1-year exams was 58%, 72% and 62% respectively. When we analyzed the data by disease location between pre- and post- educational intervention, percentage of correct answers increased only for images of left lower lobe (LLL) disease, rising from 61% to 88 % (p<0.01), and right middle lobe (RML), increasing from 61% to 88 % (p=0.015). For RML disease images, the percentage of correct answers remained 64 % after 1 year (p=0.007). Conclusion: A standardized lecture on chest X-ray reading enhanced residents’ ability to diagnose pneumonia. While improvements were short-lived, the intervention was particularly effective for difficult-to-diagnose areas such as right middle lobe disease.

Background: Some epidemiologic studies have proven the possible association between the serum level of 25-hydroxy vitamin D [25(OH)D] and the forced expiratory volume in 1 second (FEV1 ) or chronic obstructive pulmonary disease (COPD). Purpose: To investigate whether serum concentrations of 25(OH)D play a role in the diagnosis of COPD in a working population.

Patients and methods: A total of 299 industrial workers aged ≥ 40 years performed spirometry and had their serum level of 25(OH)D measured.

Results: The prevalence of COPD defined by the fixed ratio was 14.1%. Mean 25(OH)D levels did not differ significantly between subjects with COPD and those without COPD as defined by the fixed ratio (24.6 ng/mL ± 6.7 ng/ mL in subjects with COPD vs. 24.0 ng/mL ± 5.9 ng/mL in subjects without COPD; not significantly different). According to an Endocrine Society Clinical Practice Guideline released in the US in 2011, vitamin D insufficiency, defined as 25(OH)D levels of <30 ng/mL, was present in 252 (84.2%) out of the 299 participants, and vitamin D deficiency, defined as 25(OH)D levels of <20 ng/mL, was found in 80 (26.8%) subjects. Forced expiratory volume in 1 second (FEV1 ), forced vital capacity (FVC), FEV1 /FVC and the prevalence of subjects with COPD were not significantly different among the three groups with different 25(OH)D levels (≧ 30 ng/mL, ≧ 20 and <30 ng/mL and <20 ng/mL). Statistically significant correlations were not found between any measurements obtained from spirometry, including FEV1, FEV1 / FVC, and 25(OH)D levels.

Conclusion: Although vitamin D insufficiency and deficiency were frequently observed in the present study, the serum 25(OH)D concentration was not different between COPD and non-COPD subjects in a working population. The association between 25(OH)D levels and COPD did not meet a level of statistical significance in the present study conducted in a working population.

Objective: Correct inhalation technique is crucial for drug delivery to the airways of Asthma and COPD patients. The aim of the current study is to assess the usability of three commonly used DPI devices in Greece in Asthma and COPD patients.

Methods: This was a non-interventional, multicenter, observational study that enrolled 755 patients (409 Asthma and 346 COPD). Evaluation of device use was performed at baseline (day 0), immediately after correct use demonstration by the investigator, and final visit (day 30). Assessment was based on 8-step device-specific checklists where all the required inhalation maneuvers were described. Primary variable was the number of critical errors observed during baseline and final visit. The ACQ and CAT questionnaires were used to record patients’ perspective about their condition, and the FSI-10 questionnaire to depict patients’ feeling of satisfaction from inhaler use.

Results: More than 70% of the patients performed all inhalation maneuvers correctly right after the first demonstration by pneumonologist. At final visit approximately 85% of Diskus®, 93% of Elpenhaler®, and 75% of Turbuhaler® users did not make critical errors that affect drug delivery to the lungs. Elpenhaler® had the lower error rates for critical steps at baseline and final visits (7.0% and 2.5% respectively), whereas the corresponding rates for Diskus® were 7.3% and 4.9%, and for Turbuhaler®, 8.5% and 7% respectively. All patients had improved ACQ and CAT scores and were at least fairly satisfied by their inhalers.

Conclusions: Demonstration of inhalation technique is of paramount importance, while prescribing an inhaled therapy. Improvement over one-month use was more evident in Elpenhaler® device. The lower error rates on critical steps for Elpenhaler® reported at baseline and final visits in combination with the observed improvements in ACQ, CAT and FSI-10 scores suggest better adherence to therapy and disease control.

Allergic bronchopulmonary aspergillosis (ABPA) is a pulmonary disorder, occurring mostly in asthmatic and cystic fibrosis patients, caused by an abnormal T-helper 2 lymphocyte response of the host to Aspergillus fumigatus antigens. ABPA diagnosis is defined by clinical, laboratory and radiological criteria including active asthma, immediate skin reactivity to A. fumigatus antigens, total serum IgE levels>1000 IU/mL, fleeting pulmonary parenchymal opacities and central bronchiectases that represent an irreversible complication of ABPA. Despite advances in our understanding of the role of the allergic response in the pathophysiology of ABPA, pathogenesis of the disease is still not completely clear. In addition, the absence of consensus regarding its prevalence, diagnostic criteria and staging limits the possibility of diagnosing the disease at early stages. This may delay the administration of a therapy that can potentially prevent permanent lung damage. Long-term management is still poorly studied. Present primary therapies, based on clinical experience, are not yet standardized. These consist in oral corticosteroids, which control acute symptoms by mitigating the allergic inflammatory response, azoles and, more recently, anti-IgE antibodies. The latter two are used as a steroid-sparing agent to prolong the remission stage of the disease. Anti-IgE antibodies also have immunomodulatory properties. At present, the only way to bypass these limits and allow for an early diagnosis, is to assume ABPA in all patients with difficult-to-control asthma or cystic fibrosis. They should then be screened for sensitization to A. fumigatus antigens and, if positive, monitored more closely. Future controlled studies are needed to standardize present therapy, standardize cut-off values of various investigations, define the role of different novel immunomodulatory therapies, define the role of novel assays (such as recombinant A. fumigatus antigens and CCL17) and confirm new diagnostic and staging criteria.

Sirolimus is a potent immunosuppressant medication and is used in renal transplant patients to prevent acute graft rejection. Various pulmonary toxicities in patients treated with sirolimus include cough, desquamative interstitial pneumonia (DIP), diffuse interstitial pneumonia, diffuse alveolar damage (DAD), diffuse alveolar hemorrhage (DAH), alveolar phospholipoproteinosis and pulmonary hypertension with features of hemolytic uremic syndrome (HUS). We describe a case of a patient with an insidious development of chest X-ray (CXR), computed tomography of the chest (CT chest) and pulmonary function (PFT) (mainly the DLCO) abnormalities. When this progressed, an open lung biopsy was performed revealing granulomatous inflammation consistent with a hypersensitivity reaction. The abnormalities on imaging and pulmonary function testing improved after drug discontinuation. We suggest that patients using this drug have yearly DLCOs as their pulmonary symptoms may be few. If the DLCO declines significantly then a high resolution CT Chest should be performed. If abnormal, biopsy is warranted.

Upon infection with Mycobacterium tuberculosis, only a small percentage causes active infection while the rest goes into latent infection. These latent bacilli can reactivate under immunocompromised conditions and cause active disease. Little is known about the mechanism by which the mycobacteria reactivate. A family of extracellular bacterial proteins, known as resuscitation promoting factors (Rpf) from Micrococcus luteus and M. tuberculosis has been shown to stimulate growth of dormant mycobacteria as well as reactivation of chronic tuberculosis in mice. Rpf is present as a single, essential gene in M. luteus and five homologues (rpfA-E) in M. tuberculosis. The ability to stimulate culturability and resuscitation appears to be related to muralytic activity of Rpf and they have been identified as peptidoglycan glycosidases. Rpf B has earlier been shown to interact and synergize with Rpf-interacting protein A (RipA), an endopeptidase to cleave bonds in bacterial peptidoglycan suggesting distinct role of Rpf B in cell wall hydrolysis. In order to further understand the role of other Rpfs in resuscitation of dormant mycobacteria, we used an E. coli two hybrid system to identify SucA of TCA cycle as an interacting partner of Rpf from M. tuberculosis (Rpf A, C and D) and M. luteus (RpfM). The in vivo protein-protein interaction was confirmed by M-PFC system in mycobacterial host, in vitro by FRET analysis. An enhanced expression of SucA and Rpf genes was observed during resuscitation phase. We hypothesize that during transition from nonculturable to resuscitation phase mycobacteria cleaves its hard breaking cell wall by endopeptidase RipA interacting with Rpf B and increases its metabolic energy generation by evoking TCA cycle, interacting with Rpf A, C and D and could serve as prospective target along with Rpfs and RipA for development of new anti-tuberculosis drugs preventing reactivation of dormant bacilli.

Recently, idiopathic pulmonary fibrosis (IPF) associated with hypothyroidism was proposed as a possible link showing worse prognosis than IPF. We have reviewed our archives of interstitial pneumonias (IPs) and examined pathologic and clinical features of IPs associated with hypothyroidism to understand its variations. Pathologically, two cases showed usual interstitial pneumonia pattern, and one case showed non-specific interstitial pneumonia pattern. Small airway disease was a common histological feature in all cases. Two cases showed association with flavor of connective tissue disease (CTD). Diagnoses by multidisciplinary discussion for the three cases were IPF, unclassifiable IP, and systemic sclerosis associated interstitial lung disease. Our cases indicated that IPs associated with hypothyroidism may show not only IPF but also other histological types and probable connection to CTD. Furthermore, these three cases did not fit with predicted prognosis by histological patterns.

Desmoid tumors of the chest are rare and invasive tumors. We report the case of a 66-year-old patient operated through a Cormier Dartevelle Grunewald incision. After resection of the first two ribs to improve exposition, we proceeded to a careful control of the proximal and distal extremities of the sub-clavian artery that was invaded by the tumor. A termino-terminal anastomosis was performed after removal of the invaded segment. One-piece resection was not possible because of the size of the mass. The resection of the intra-foraminal extension was performed with an intra-thoracic approach by a neurosurgeon. The postoperative course was uneventful.

Background: Acute respiratory infection is an infection that affects children younger than 5 years from 3 to 8 episodes per year. 1.2. Aim of the Study: identification the prevalence of chest-related ARI symptoms among children less than 5 years in Upper Egypt and its determinants. Methods: The Secondary analysis was done based on data sets of Egypt Demographic Health Survey (DHS) 2008 targeting 4,745 children living in Upper Egypt Governorates. Results: The present study included 4,745 children less than 5 years in Upper Egypt who included in DHS 2008 with the mean age 28.27 months. It was found that 891 suffered from a cough during the two-week period before the DHS survey with a prevalence of 18.8%. Less than three quarters of them had experienced short or rapid breathing because of a problem in the chest or/and the nose. Children aged 6 to 23 months and male children were the most likely had chestrelated acute respiratory tract infection symptoms. Conclusion: Children aged 6 to 23 months and male children were the most likely had the symptoms.