Novel management strategies for idiopathic pulmonary fibrosis

INTRODUCTION

Idiopathic pulmonary fibrosis (IPF) treatment was revolutionized by the advent of two novel antifibrotics, nintedanib and pirfenidone. However, neither is a panacea and other agents are still sorely needed. This review presents on-going efforts to improve outcomes for patients with IPF by targeting novel pharmacologic pathways, improving comorbidity management, and aiming for improved quality of life. Areas covered: We provide an overview of on-going basic and clinical science efforts focused on development of additional drug therapies for patients with IPF. Known and emerging pathogenic pathways such as the microbiome and pulmonary vasculature hold promise as targets for therapy. While the focus remains on pharmacologic intervention, the impact of comorbidities and their management may also impact patient outcomes significantly. Supportive care with pulmonary rehabilitation, oxygen therapy, and palliative care remain integral at various stages of the disease course. Finally, lung transplant is the only lifesaving intervention for patients with end-stage fibrosis. Expert commentary: Future investigation should aim to prevent the initial insult or injury that engages the multiple pathways associated with the development and progression of IPF. Targeted therapies represent just one management aspect with a multidisciplinary approach necessary for the global holistic care of these complex patients.

Association of Socio-Demographic Profile with Prevalence of Multi Drug Resistant Tuberculosis among Retreated Pulmonary Tuberculosis Patients in North India

Methods: An observational cross sectional study, which includes 116 patients of sputum smear positive pulmonary TB of age 18 or above. Further, detailed history taking regarding different demographic profile was done. Also, they were subjected to CB-NAAT and rifampicin resistant cases were considered as MDR-TB. Results: Proportion of MDR-TB was 31.89% among retreatment TB cases. 56.75 % (n=21) of MDR-TB cases were between the age group of 21-40 years. Proportion of MDR-TB was higher among males (75.67%), married (59.45%) and rural dwellers 59.45%. Proportion was 61.76% among patients with BMI <16; 31.57% with BMI 16-16.99, 28.57% with BMI 17-18.49 and 5.7% with BMI 18.50-24.99. MDRTB proportion was less 29.72% (n=11) in patients with history of TB contact in family. Pulmonary TB including MDR-TB was more common among illiterates (37.83% among MDR). Conclusion: Proportion of MDR-TB was high among retreatment cases in north India. Among them low BMI and education status are modifiable factor and this study signifies that MDR-TB burden can be reduced by improving health and education status of patient.

Mucormycosis pulmonary abscess, containment in a patient with uncontrolled diabetes mellitus

A 56-year-old Hispanic male with solo risk factor of uncontrolled diabetes mellitus presented with recurrent haemoptysis. Initial concern was for malignancy with postobstructive pneumonia; however, invasive testing and biopsy confirmed infectious mass of fungal aetiology requiring surgical resection followed by a prolonged course of anti-fungal therapy. Discussion centred on approach to, progression of and course of action in the management of pulmonary abscess due to mucormycosis.

Dysregulated Nox4 ubiquitination contributes to redox imbalance and age-related severity of acute lung injury

Acute respiratory distress syndrome (ARDS) is a devastating critical illness disproportionately affecting the elderly population, with both higher incidence and mortality. The integrity of the lung endothelial cell (EC) monolayer is critical for preservation of lung function. However, mechanisms mediating EC barrier regulation in the context of aging remain unclear. We assessed the severity of acute lung injury (ALI) in young (2 mo) and aged (18 mo) mice using a two-hit preclinical model. Compared with young cohorts, aged mice exhibited increased ALI severity, with greater vascular permeability characterized by elevated albumin influx and levels of bronchoalveolar lavage (BAL) cells (neutrophils) and protein. Aged/injured mice also demonstrated elevated levels of reactive oxygen species (ROS) in the BAL, which was associated with upregulation of the ROS-generating enzyme, Nox4. We evaluated the role of aging in human lung EC barrier regulation utilizing a cellular model of replicative senescence. Senescent EC populations were defined by increases in β-galactosidase activity and p16 levels. In response to lipopolysaccharide (LPS) challenge, senescent ECs demonstrate exacerbated permeability responses compared with control "young" ECs. LPS challenge led to a rapid induction of Nox4 expression in both control and senescent ECs, which was posttranslationally mediated via the proteasome/ubiquitin system. However, senescent ECs demonstrated deficient Nox4 ubiquitination, resulting in sustained expression of Nox4 and alterations in cellular redox homeostasis. Pharmacological inhibition of Nox4 in senescent ECs reduced LPS-induced alterations in permeability. These studies provide insight into the roles of Nox4/senescence in EC barrier responses and offer a mechanistic link to the increased incidence and mortality of ARDS associated with aging.

Incorporating HIV/hepatitis B virus/hepatitis C virus combined testing into routine blood tests in nine UK Emergency Departments: the "Going Viral" campaign

OBJECTIVES

Routine HIV screening is recommended in those UK hospitals and primary care settings where the HIV prevalence is > 0.2%. For hepatitis B virus (HBV) and hepatitis C virus (HCV), however, testing is targeted at at-risk groups. We investigated the prevalence of these blood-borne viruses (BBVs) during a routine testing pilot in UK Emergency Departments (EDs).

METHODS

During the "Going Viral" campaign (13-19 October 2014), nine UK EDs in areas of high HIV prevalence offered routine tests for HIV, HBV and HCV to adults having blood taken as part of routine care. Patients who tested positive were linked to care.

RESULTS

A total of 7807 patients had blood taken during their ED visit; of these, 2118 (27%) were tested for BBVs (range 9-65%). Seventy-one BBV tests were positive (3.4%) with 32 (45.1%) new diagnoses. There were 39 HCV infections (15 newly diagnosed), 17 HIV infections (six newly diagnosed), and 15 HBV infections (11 newly diagnosed). Those aged 25-54 years had the highest prevalence: 2.46% for HCV, 1.36% for HIV and 1.09% for HBV. Assuming the cost per diagnosis is £7, the cost per new case detected would be £988 for HCV, £1351 for HBV and £2478 for HIV.

CONCLUSIONS

In the first study in the UK to report prospectively on BBV prevalence in the ED, we identified a high number of new viral hepatitis diagnoses, especially hepatitis C, in addition to the HIV diagnoses. Testing for HIV alone would have missed 54 viral hepatitis diagnoses (26 new), supporting further evaluation of routine BBV testing in UK EDs.

Cranial Ultrasonography in Infantile Encephalitic Beriberi: A Useful First-Line Imaging Tool for Screening and Diagnosis in Suspected Cases

BACKGROUND AND PURPOSE

Brain imaging is central to the diagnosis of infantile encephalitic beriberi. Because cranial sonography findings have not been described in infantile encephalitic beriberi, our aim was to investigate its role in the diagnosis of this condition.

MATERIALS AND METHODS

We performed a retrospective review of head sonography of infants (admitted between November 1, 2014, and March 31, 2015) who presented with encephalopathy. Cranial ultrasonography scans were studied for the alteration of echogenicity of the basal ganglia.

RESULTS

Of the 145 consecutive infants who presented with encephalopathy, 58 had thiamine-responsive encephalopathy (infantile encephalitic beriberi) and 87 had encephalopathy due to other causes. Forty-eight of 145 infants with encephalopathy showed hyperechoic basal ganglia. A hyperechoic appearance of the basal ganglia on cranial ultrasonography was found to have a sensitivity of 71% (41/58) and a specificity of 92% (80/87) in diagnosing infantile encephalitic beriberi. The sensitivity of cranial sonography increased with age. It was a maximum of 93% (14/15) in the 5 months and older age group. Specificity was a maximum of 100% (18/18) in infants older than 5 months of age. Sensitivity was maximum in Wernicke encephalopathy at 90% (18/20) and least in the acidotic form at 43% (10/23). Follow-up showed gradual normalization of the hyperechoic appearance of the basal ganglia during 8 weeks in 26/41 (63%), with mild atrophy of the basal ganglia in 6/41 (15%)

CONCLUSIONS

Hyperechogenicity of the basal ganglia on cranial ultrasonography is a sensitive finding for the diagnosis of infantile encephalitic beriberi in infants who present with Wernicke encephalopathy.

An exploratory study on speech and hearing outcomes in children with cleft lip and palate

INTRODUCTION

Little is known about the treatment outcomes of children with cleft lip and/or palate (CLP) receiving surgical care for primary lip and palate closure in Malaysia.

OBJECTIVES

This study examined the speech and hearing status of Malay-speaking children with CLP residing in Kuala Lumpur.

METHODS

Parents whose children were between the age of 5 and 7 years were recruited via the Cleft Lip and Palate Association of Malaysia (CLAPAM) registry. Parents completed a survey and the children completed a speech and hearing assessment at the Audiology and Speech Sciences Clinic, Universiti Kebangsaan Malaysia.

OUTCOMES

Speech measures include nasality rating, nasalance scores, articulation errors and speech intelligibility rating, while hearing measures include hearing thresholds and tympanometry results for each child.

RESULTS

Out of 118 registered members who fulfilled the inclusion criteria, 21 agreed to participate in the study. The overall speech and hearing status of children in this sample were poor. Only four (19%) participants had normal speech intelligibility rating and normal hearing bilaterally. In terms of overall cleft management, only four (19%) participants were seen by a cleft team while seven (33%) had never had their hearing tested prior to this study.

CONCLUSION

Participants in this sample had poor outcomes in speech and hearing and received uncoordinated and fragmented cleft care. This finding calls for further large scale research and collaborative efforts into improving and providing centralised, multidisciplinary care for children born with CLP.

Routine HIV testing within the emergency department of a major trauma centre: a pilot study

OBJECTIVES

UK guidelines recommend routine HIV testing for all medical admissions where the local prevalence exceeds 2 per 1000. We aimed to review uptake of HIV testing in the emergency department (ED) of one of the country's major trauma centres in a 3-month pilot study (March-June 2013).

METHODS

ED attendees already having blood tests were routinely tested for HIV (based on the recommendation being made to all to test when having blood taken). Uptake was determined using the surrogate marker of ED attendees who had full blood counts (FBCs) as the denominator. Newly diagnosed patients were linked to care and contacts tested. Staff completed an anonymous online survey to determine acceptability at the end of the pilot study.

RESULTS

A total of 2828 patients were tested over 3 months. Nineteen HIV-positive individuals were identified. Eight were newly diagnosed, of whom two were thought to be seroconverting. The prevalence of new diagnoses was 8/2828 (0.28%); for comparison, the Public Health England (PHE) actual prevalence for Tower Hamlets is 6.25/1000 (0.625%). Uptake for HIV testing was 30%, a significant increase from 72 tests performed in the 2 months prior (P < 0.001). Ninety-five per cent of respondents to the staff survey agreed that routine HIV testing should be rolled out permanently in the ED.

CONCLUSIONS

Despite an average uptake rate, there were 19 positive tests: eight in patients who were newly diagnosed, six in patients who had been lost to follow-up, and five in patients who were known to be positive and linked to care. The staff survey indicated recognition of the importance of HIV testing in the ED. These persuasive data achieved short-term Clinical Commissioning Group (CCG) funding for routine ED testing.

Inhibition of class I HDACs abrogates the dominant effect of MLL-AF4 by activation of wild-type MLL

The ALOX5 gene encodes 5-lipoxygenase (5-LO), a key enzyme of inflammatory reactions, which is transcriptionally activated by trichostatin A (TSA). Physiologically, 5-LO expression is induced by calcitriol and/or transforming growth factor-β. Regulation of 5-LO mRNA involves promoter activation and elongation control within the 3'-portion of the ALOX5 gene. Here we focused on the ALOX5 promoter region. Transcriptional initiation was associated with an increase in histone H3 lysine 4 trimethylation in a TSA-inducible manner. Therefore, we investigated the effects of the MLL (mixed lineage leukemia) protein and its derivatives, MLL-AF4 and AF4-MLL, respectively. MLL-AF4 was able to enhance ALOX5 promoter activity by 47-fold, which was further stimulated when either vitamin D receptor and retinoid X receptor or SMAD3/SMAD4 were co-transfected. In addition, we investigated several histone deacetylase inhibitors (HDACi) in combination with gene knockdown experiments (HDAC1-3, MLL). We were able to demonstrate that a combined inhibition of HDAC1-3 induces ALOX5 promoter activity in an MLL-dependent manner. Surprisingly, a constitutive activation of ALOX5 by MLL-AF4 was inhibited by class I HDAC inhibitors, by relieving inhibitory functions deriving from MLL.Conversely, a knockdown of MLL increased the effects mediated by MLL-AF4. Thus, HDACi treatment seems to switch 'inactive MLL' into 'active MLL' and overwrites the dominant functions deriving from MLL-AF4.

Hemangioma presenting as a painful neck mass: A case report

Hemangiomas of muscles are rare congenital benign vascular tumors usually seen on the trunk and extremities, but can also appear on the head and neck regions. In a young adult with soft tissue attenuation mass in the skeletal muscle, hemangioma should be considered in the differential diagnosis. Ultrasound and computed tomography are the useful imaging modalities for the diagnosing of hemangioma and complete surgical excision is the treatment of choice. We report a case of 24 year old woman with an intramuscular hemangioma involving the posterior neck muscles who presented to our department with painful neck mass. Journal of College of Medical Sciences-Nepal, 2013, Vol-9, No-1, 56-59 DOI: http://dx.doi.org/10.3126/jcmsn.v9i1.9674

MRI evaluation of knee injury with arthroscopic correlation

BACKGROUND

Magnetic Resonance Imaging has emerged as the primary investigation for evaluation of the knee injury because of its high resolution and accuracy and it has often been regarded as the noninvasive alternative to diagnostic arthroscopy. The objective of this study was to find out the various types of traumatic lesions of the knee on MRI, to correlate the results with arthroscopy, and to establish the accuracy of MRI in detecting ligament and meniscal injury.

METHODS

This cross sectional study was conducted on 40 patients with knee injury over a period of one year. MRI of the knee followed by arthroscopy was performed in each case. Arthroscopy was done within 30 days of MRI examination and was considered as gold standard.

RESULTS

Various types of lesion seen on MRI were as follows: joint effusion 27 (67.5%), anterior cruciate ligament tear 23 (57.5%), medial meniscus tear 20 (50%), bone contusion 18 (45%), lateral meniscus tear 16 (40%), medial collateral ligament injury 16 (40%), lateral collateral ligament injury 14 (35%) and posterior cruciate ligament tear 14 (35%). Sensitivity, specificity and accuracy of MRI in detecting meniscal and cruciate ligament injury were as follows: medial meniscus: 85.7%, 89.4%, 87.5%; for lateral meniscus: 83.3%, 95.4%, 90%; for anterior cruciate ligament: 91.3%, 88.2%, 90%; and for posterior cruciate ligament: 92.8%, 96.1%, 95% respectively.

CONCLUSIONS

MRI is a noninvasive, useful and reliable diagnostic tool for evaluating knee injury and it can be used as a first line investigation in patients with knee injury.

Antenatal diagnosis of achondroplasia

We report a interesting case of antenatal diagnosis of achondrpoplasia in a young multigravida who presented with term pregnancy for routine ultrasound assessment which revealed a single, live intrauterine fetus with a discrepancy between femur length (FL) and biparietal diameter (BPD), narrowing of the interpeduncular distance. The diagnosis of achondroplasia was made with a sonological skeletal survey and findings were correlated with radiological skeletal survey after the baby was delivered. DOI: http://dx.doi.org/10.3329/bjms.v13i1.17443 Bangladesh Journal of Medical Science Vol. 13 No. 01 January2014: 84-87

Congenital pseudoarthrosis of the clavicle: a case report

DOI: http://dx.doi.org/10.3126/jcmsn.v8i3.8687 Journal of College of Medical Sciences-Nepal,2012,Vol-8,No-3, 43-46  

Association between Serum 25 (OH) Vitamin D Concentrations and Inflammatory Bowel Diseases (IBDs) Activity

Inflammatory bowel diseases (IBDs) are immune mediated diseases affecting the gastrointestinal tract. Several environmental factors in concert with genetic susceptibilities can trigger IBDs. Recently, one of the important environmental factors contributing to the development of autoimmune diseases is vitamin D (VitD) deficiency. Furthermore, some new evidence points to VitD deficiency and its receptor dysfunction as an underlying factor for the emergence experimental IBDs. The aim of the current study was to evaluate the correlation between serum 25(OH)D concentrations and IBD activity in patients with ulcerative colitis or Crohn's disease. Sixty patients with confirmed diagnosis of IBD were recruited for a cross sectional study. Most of the identified confounders affecting serum VitD concentrations were excluded. Disease activity was assessed using validated questionnaires, including Truelove for Ulcerative Colitis and Crohn Disease Activity Index (CDAI) for Crohn disease. Serum 25(OH)D concentrations were determined by chemiluminescent assay. Serum 25(OH)D≤10 (ng/ml) was considered as VitD deficiency and 11≤25(OH)D<29(ng/ml) as VitD insufficiency. Mean serum 25(OH)D value was 13.1 ± 11.1(ng/ml) in IBD patients. Almost 95% of patients were vitamin D insufficient or deficient. Forty one percent of IBD patients had active disease. VitD deficiency was not associated with IBD activity (p=0.23). However, VitD deficiency was significantly associated with a history of IBD related intestinal surgery (p=0.001). In conclusion, this cross-sectional prospective study suggested that there is no association between vitamin D deficiency and disease activity in a relatively small number of IBD patients in a short period of time.