Factors Influencing Early Diagnosis and Poor Prognosis of Dysphagia After Senile Ischemic Stroke

Dysphagia is often a long-term problem after ischemic stroke, which are often accompanied by complications and results in poor outcome. This study aimed to investigate the influencing factors associated with the prognosis of dysphagia after senile ischemic stroke and evaluate the diagnostic performance of crucial factors. A total of 192 elderly ischemic stroke patients (96 patients without dysphagia with average age of 69.81 ± 4.61 years and 96 patients with dysphagia with average of 70.00 ± 6.66 years) were enrolled in the retrospective study. The clinical factors of the patients were collected and recorded for chi-square analysis and logistic analysis. The receiver operating characteristic (ROC) curve was performed to evaluate the diagnostic performance of international normalized ratio (INR) and homocysteine (Hcy) in senile ischemic stroke patients. The age, cough reflex, history of stroke, mechanical ventilation, eating posture, insufficient elevation of the larynx, standard swallowing assessment (SSA) score, Hcy value, and INR were closely related to endpoint events of patients with dysphagia. The joint model (combined INR and Hcy value) can increase the area under the curve (AUC) value (0.948) with higher sensitivity and specificity for predicting patients with dysphagia occurred endpoint events. The influencing factors for older ischemic stroke patients with dysphagia include age, cough reflex, history of stroke, mechanical ventilation, eating posture, insufficient elevation of the larynx, SSA score, Hcy value, and INR. INR and Hcy were independent risk factors for prognosis and diagnostic markers for patients with dysphagia after senile ischemic stroke.

Cough Correlates of Functional Swallow Outcomes in Atypical Parkinsonism

BACKGROUND

Swallow and cough impairments lead to aspiration and reduced clearance of aspirate material. Both behaviors are impaired in Parkinson's disease, but it is unknown whether a similar relationship of dysfunction exists in forms of atypical Parkinsonism (APD). Elucidating this association in APD may lead to early, comprehensive airway protection treatment.

OBJECTIVES

We tested the hypotheses that swallow deficits in APD are associated with impaired cough and that airway protective dysfunction is associated with longer disease duration.

METHODS

Swallowing difficulty was described by 11 participants with APD. Penetration-Aspiration Scale (PAS) and DIGEST scores for thin liquid trials were extracted from medical records of videofluoroscopic swallow study reports. Voluntary and capsaicin induced-reflex cough measures of flow, volume, and timing were analyzed.

RESULTS

While most participants did not have post-swallow residue, ~80% received abnormal PAS scores and reported swallowing difficulty. Those with abnormal PAS scores had lower voluntary cough expired volume (P = 0.037; mean rank difference = 5.0); lower reflex inspiratory flow rate (P = 0.034; mean rank difference = 5.5); and longer reflex expiratory flow rise time (P = 0.034; mean rank difference = 5.5). Higher PAS scores and reduced reflex cough volume acceleration were significantly correlated (r = -0.63; P = 0.04) and longer disease duration predicted larger voluntary cough expired volume (R2  = 0.72) and longer flow rise times (R2  = 0.47).

CONCLUSIONS

As swallow safety worsens, so might the ability to clear the airways with effective cough in in APD; particularly with longer disease duration. Assessing cough in conjunction with swallowing is important for informing airway protection treatment plans in APD.

Effect of intravenous and topical laryngeal lidocaine on sore throat after extubation: a prospective randomized controlled study

OBJECTIVE

The present study aimed to compare the effect of topical laryngeal lidocaine with intravenous lidocaine before endotracheal intubation on the incidence and severity of postoperative sore throat, hoarseness, and cough.

PATIENTS AND METHODS

This prospective randomized controlled study enrolled 144 patients undergoing laparoscopic cholecystectomy with endotracheal intubation. The patients were randomized to three groups and received 2% lidocaine by topical laryngeal spray (group T), intravenous 2% lidocaine (group I), and the equivalent volume of intravenous saline (group C) before intubation. The incidence and severity of sore throat, hoarseness, and cough reaction at 0.5, 1, 6, and 24 h after extubation were collected.

RESULTS

The incidence of sore throat was significantly lower in group T than in groups I and C (6.4% vs. 37.2% and 86.7%, p < 0.001), respectively at 0.5 h after extubation, and it was significantly lower in group I than that in group C (37.2% vs. 86.7%, p < 0.001). Both the incidence of hoarseness and cough were significantly lower in group T than in group I and in group C (14.9% vs. 97.7% and 97.8%, p < 0.001, and 19.1% vs. 72.0% and 93.3%, p < 0.001), respectively. The severity of sore throat, hoarseness and cough in group T was significantly lower than that in group I and that in group C (p < 0.05), and it was significantly lower in group I than in group C (p < 0.05).

CONCLUSIONS

Both topical laryngeal lidocaine and intravenous lidocaine before intubation have positive effects on preventing sore throat. Topical laryngeal route was superior to intravenous route. Chictr.org.cn ID: ChiCTR2100042442.

Long-term outcome after surgical management of symptomatic non-union rib fractures

INTRODUCTION

Traumatic chest wall injuries are common however the incidence of non-union rib fractures is unknown. Previous studies have suggested that surgical management of symptomatic non-union rib fractures could be beneficial in selected patients, although many experience persisting pain despite surgery. The aim of this study is to investigate the long-term outcome after surgical management of symptomatic non-union rib fractures.

METHODS

This is a cross-sectional study including adults (≥18 years) managed surgically for symptomatic non-union rib fractures with plate fixation during the period 2010-2020 at Sahlgrenska University Hospital. Patients operated for acute chest wall injury or injury due to cardiopulmonary resuscitation were excluded. Patients answered standardized questionnaires concerning remaining symptoms and satisfaction with surgery, quality of life (QoL, EQ-5D-5 L) and disability (Disability Rating Index, DRI). Lung function, movement of chest wall and thoracic spine, and shoulder function (Boström index) were assessed.

RESULTS

Sixteen patients, 12 men and four women, with mean age 61.6± 11.1 were included in the study. The mechanism of injury was trauma in 10 patients and cough-induced injuries in five patients. Lung disease was significantly more prevalent in cough-induced injuries compared to traumatic injuries, 5 vs 1 (p = 0.008). The mean follow-up time was 3.5 years. Ninety-four percent were satisfied with the surgery and reported that their symptoms had decreased, although 69 % had remaining symptoms, especially pain, from the chest wall. Quality of Life was decreased with EQ-5D-5 L index 0.819 (0.477-0.976) and EQ-VAS 69 (10-100). Disability Rating Index was 31.5 (1.3-76.7) with problems running, lifting heavy objects, and performing heavy work. Predicted lung function was decreased with Forced Vital Capacity (FVC) 86.2 ± 14.2 %, Forced Expiratory Volume in 1 second (FEV1) 79.1 ± 10.7 % and Peak Expiratory Flow (PEF) 89.7 ± 14.5 %. Patients with cough-induced injuries had full shoulder mobility.

CONCLUSIONS

Chest wall surgery for symptomatic non-union rib fractures results in decreased symptoms and patient satisfaction in most cases despite remaining symptoms, reduced lung function, chest wall movement, and QoL and persistent disability.

Achalasia-associated megaoesophagus presenting with dyspnoea and cough

We present an unusual case of achalasia presenting with dyspnoea and persistent cough. These symptoms persisted for months, leading to the patient undergoing a chest X-ray by her general practitioner which showed right basal consolidation and a density extending along the right mediastinum. CT scan was done which revealed megaoesophagus with a diameter of 7 cm causing tracheal compression, as well as right basal consolidation, consistent with aspiration. Further history revealed 6-month history of progressive swallowing difficulty, retrosternal chest pain and shortness of breath which worsened when eating solid foods. After thorough workup, a diagnosis of idiopathic achalasia (type II) was made. She was treated with laparoscopic Heller cardiomyotomy and Dor fundoplication with significant improvement at follow-up. Dyspnoea and respiratory symptoms are unusual presenting symptoms, suggesting a need to consider achalasia in a wider range of presentations. Successful treatment of achalasia depends on timely diagnosis and intervention prior to oesophageal failure.

Prolonged cough and dyspnea following a single episode of intense silica exposure

Long term exposure to silica at worksites can cause silicosis. This typically has two radiographic forms, simple silicosis and complicated or conglomerate silicosis. Patients with acute silicosis have rapid progression of disease with fulminant respiratory failure over months rather than years. The patient described in this case report had a one-time 4 to 5-h exposure to silica and sand dust at work when his mask malfunctioned. He developed cough and shortness of breath. During his initial clinic visit he had significant cough. His chest examination was clear without crackles or wheezes. His pulmonary function tests were within normal limits. His chest x-ray was clear. Both symptoms, especially the cough, persisted over the next 6+ months even after treatment with oral corticosteroids and inhaled corticosteroids and long-acting beta agonists. Consequently, this patient developed severe cough following a one-time exposure to silica particulates. Laboratory studies have demonstrated that silica exposure can cause reactive oxygen species which potentially could have activated transient receptor potential vanilloid 1 channels in the afferent sensory nerves in his bronchial epithelium. This could cause sustained cough for more than 6 months. His symptoms improved but did not resolve with corticosteroid treatment. Therefore, this case demonstrates that acute silica exposure can cause sustained airway symptoms in healthy workers.

Congenital bronchoesophageal fistula in an adult patient

INTRODUCTION

Congenital bronchoesophageal fistulas are extremely rare. Symptoms may not be detected before treatment or may be seen intermittently until advanced ages. Treatment is surgical closure of the fistula.

CASE PRESENTATION

A 20-year-old female patient with presented complaints of sputum production and cough. A fistula was confirmed between the middle esophagus and the left main bronchus by bronchoscopy. Management is by surgical closure of the fistula via right thoracotomy. The patient had an uneventful recovery.

CONCLUSION

Congenital bronchoesophageal fistula malformation can cause long-term respiratory symptoms associated with the fistula and loss of lung parenchyma if left untreated.

Management of mixed urinary incontinence: IUGA committee opinion

INTRODUCTION AND HYPOTHESIS

Mixed urinary incontinence (MUI) is defined by the International Urogynecology Association (IUGA) and International Continence Society as the complaint of involuntary leakage of urine associated with urgency and also with exertion, effort, sneezing or coughing. It therefore implies the coexistence of both stress urinary incontinence (SUI) and urgency urinary incontinence (UUI). MUI is a heterogeneous diagnosis that requires an assessment of its individual components of SUI and UUI. Management requires an individualised approach to the symptom components. The aim of this review is to identify the assessment/investigations and management options for MUI.

METHODS

A working subcommittee from the IUGA Research & Development (R&D) Committee was created and volunteers invited from the IUGA membership. A literature review was performed to provide guidance focused on the recommended assessment and management of MUI. The document was then evaluated by the entire IUGA R&D Committee and IUGA Board of Directors and revisions made. The final document represents the IUGA R&D Committee Opinion.

RESULTS

The R&D Committee MUI opinion paper provides guidance on the assessment and management of women with MUI and summarises the evidence-based recommendations.

CONCLUSIONS

Mixed urinary incontinence is a complex problem and successful management requires alleviation of both the stress and urge components. Care should be individualised based on patient preferences. Further research is needed to guide patients in setting goals and to determine which component of MUI to treat first. The evidence for many of the surgical/procedural treatment options for MUI are limited and needs to be explored in more detail.

Relationship between dyspnoea and related factors in patients with cancer: a cross-sectional study

OBJECTIVES

Dyspnoea is a common and distressing symptom in patients with cancer. We aimed to analyse the association between dyspnoea and related factors and to estimate their causal relationship.

METHODS

A cross-sectional study was conducted. Patients with cancer with dyspnoea and a mean Numerical Rating Scale (NRS) of ≥3 over 24 hours were enrolled at 10 institutions in Japan from December 2019 to February 2021. The outcomes included dyspnoea, cough and pain NRS over 24 hours, Eastern Cooperative Oncology Group Performance Status, Hospital Anxiety and Depression Scale, Somatosensory Amplification Scale, opioids for dyspnoea and respiratory failure. Path analyses were conducted to estimate the direct and indirect paths with reference to dyspnoea and related factors.

RESULTS

A total of 209 patients were enrolled and 208 patients were included in the analysis. Cough worsened dyspnoea (β=0.136), dyspnoea increased emotional distress (β=1.104), emotional distress increased somatosensory amplification (β=0.249) and somatosensory amplification worsened cough (β=0.053) according to path analysis.

CONCLUSION

There may be a vicious circle among dyspnoea and related factors: cough worsened dyspnoea, dyspnoea increased emotional distress, emotional distress increased somatosensory amplification and somatosensory amplification worsened cough. When treating dyspnoea in patients with cancer, managing these factors aimed at interrupting this vicious circle may be useful.

TRIAL REGISTRATION NUMBER

UMIN Clinical Trials Registry (UMIN000038820).

Environmental risk factors for respiratory infection and wheeze in young children: A multicentre birth cohort study

INTRODUCTION

Respiratory infections and wheeze have a considerable impact on the health of young children and consume significant healthcare resources. We aimed to evaluate the effect of environmental factors on respiratory infections and symptoms in early childhood.

METHODS

Environmental risk factors including: daycare attendance; breastfeeding; siblings; damp within the home; environmental tobacco smoke (ETS); child's bedroom flooring; animal exposure; road traffic density around child's home; and solid fuel pollution within home were assessed in children recruited to the GO-CHILD multicentre prospective birth cohort study. Follow-up information on respiratory infections (bronchiolitis, pneumonia, otitis media and cold or flu), wheeze and cough symptoms, healthcare utilisation and medication prescription was collected by postal questionnaires at 12 and 24 months. Log binomial and ordered logistic regression models were fitted to the data.

RESULTS

Follow-up was obtained on 1344 children. Daycare was associated with increased odds of pneumonia (odds ratio [OR] = 2.39, 95% confidence interval [CI]: 1.04-5.49), bronchiolitis (OR = 1.40, 1.02-1.90), otitis media (OR = 1.68, 1.32-2.14) and emergency department attendance for wheeze (RR = 1.81, 1.17-2.80). Breastfeeding beyond 6 months was associated with a reduced odds of bronchiolitis (OR = 0.55, 0.39-0.77) and otitis media (OR = 0.75, 0.59-0.99). Siblings at home was associated with an increased odds of bronchiolitis (OR = 1.65, 1.18-2.32) and risk of reliever inhaler prescription (RR = 1.37, 1.02-1.85). Visible damp was associated with an increased odds of wheeze (OR = 1.85, 1.11-3.19), and risk of reliever inhaler (RR = 1.73, 1.04-2.89) and inhaled corticosteroid prescription (RR = 2.61, 1.03-6.59). ETS exposure was associated with an increased odds of primary care attendance for cough or wheeze (OR = 1.52, 1.11-2.08). Dense traffic around the child's home was associated with an increased odds of bronchiolitis (OR = 1.32, 1.08-2.29).

CONCLUSION

Environmental factors likely influence the wide variation in infection frequency and symptoms observed in early childhood. Larger population studies are necessary to further inform and guide public health policy to decrease the burden of respiratory infections and wheeze in young children.

A Term Infant Presenting with COVID-19 Disease at Birth and a Croup-Like Cough

OBJECTIVE

 Since the global outbreak of the novel coronavirus disease 2019 (COVID-19), there have been increasing reports of children developing a croup-like cough associated with concurrent COVID-19 infection. Currently, there is not much information available regarding newborn infants and COVID-19 infection and the incidence of vertical transmission is thought to be rare. This novel case report depicts a term newborn infected at the time of birth with COVID-19 and includes details about the course of their complicated hospitalization.

STUDY DESIGN

 A term infant, found to be infected at birth with COVID-19, developed respiratory distress resulting in transfer to our neonatal intensive care unit. Due to the increasing respiratory support requirements, endotracheal intubation was required on day of life (DOL) 7. Later, when the infant was extubated, on DOL 21, a croup-like cough developed.

RESULTS

 Despite respiratory treatment with albuterol, budesonide, racemic epinephrine, lidocaine, dornase alfa, and a 10-day course of dexamethasone, the cough persisted. A prolonged hospitalization was required and eventually the infant was discharged home on 0.4 L/minute of oxygen via nasal cannula on DOL 95.

CONCLUSION

 As the COVID-19 virus mutates over time, there are some seemingly different presentations in both the pediatric and adult populations. The hypervigilance and sharing of new findings among providers are paramount in the treatment of infants with COVID-19 disease.

KEY POINTS

· Term infant with COVID-19 developed a croup-like cough.. · Usual respiratory treatment not effective with croup-like cough and COVID-19.. · COVID-19 present at birth later requiring intubation..

An 85-Year-Old Man with Fever, Dyspnea, and Dry Cough Diagnosed with Idiopathic Hypereosinophilic Syndrome, Successfully Treated with High-Dose Corticosteroids

BACKGROUND Idiopathic hypereosinophilic syndrome (I-HES) is a rare disease diagnosed as absolute eosinophil count >1500 cells/µl and end-organ involvement attributable to tissue eosinophilia with no secondary cause of underlying eosinophilia. The mean age of presentation for I-HES is 44 years. The skin, lungs, and gastrointestinal (GI) system are most common sites of presenting manifestations, including fatigue, cough, dyspnea, myalgias, angioedema, rash, fever, nausea, and diarrhea. Although cardiac and neurologic symptoms are less common at presentation, they can be life-threatening. CASE REPORT We report the case of an 85-year-old man who presented with fever, malaise, and loss of appetite for 3 weeks, followed by dyspnea and dry cough for 2 weeks. His absolute eosinophil count was 9000 cells/µl, which was not responding to empirical antibiotic therapy, with worsening of symptoms, suggesting a non-infective origin. He was then extensively evaluated to establish underlying an etiology for specific treatment, which was negative for common causes like atypical infections, malignancy, and autoimmune disorders. He was then started on corticosteroid therapy to overcome an exaggerated immune response and reduce inflammation-related injury, to which he responded well. On follow-up, hypereosinophilia was fully cured, with reversal of end-organ involvement including myocarditis and pneumonitis. CONCLUSIONS This report shows that idiopathic HES can present with various clinical features and that accurate diagnosis, excluding known causes of eosinophilia, and early management are essential to prevent long-term organ damage. Our patient responded to prompt treatment with high-dose corticosteroids.

Chronic Cough as a Genetic Neurological Disorder? Insights from Cerebellar Ataxia with Neuropathy and Vestibular Areflexia Syndrome (CANVAS)

Chronic cough is common, and in many cases unexplained or refractory to otherwise effective treatment of associated medical conditions. Cough hypersensitivity has developed as a paradigm that helps to explain clinical and research observations that frequently point towards chronic cough as a neuropathic disorder. Cerebellar ataxia with neuropathy and vestibular areflexia syndrome (CANVAS) is a recently described neurological condition whose clinical features include gait ataxia, unsteadiness, peripheral neuropathy, and autonomic dysfunction. Chronic cough is also a common feature of the syndrome, with features of hypersensitivity, often preceding core neurological symptoms by up to 30 years or more. The genetic basis in a majority of cases of CANVAS appears to be biallelic variable repeat intron expansion sequences within RFC1, a gene normally involved in the regulation of DNA replication and repair. The same polymorphism has now been identified at an increased frequency in patients with unexplained or refractory chronic cough in the absence of defining clinical features of CANVAS. This review expands on these points, aiming to increase the awareness of CANVAS amongst clinicians and researchers working with chronic cough. We discuss the implications of a link between RFC1 disease and cough. Improved understanding of CANVAS may lead to an enhanced grasp of the pathophysiology of chronic cough, and new approaches to antitussive treatments.

Patient experiences with SARS-CoV-2: Associations between patient experience of disease and coping profiles

INTRODUCTION

Severe acute respiratory syndrome coronavirus 2, (SARS-CoV-2,) caused an influx of patients with acute disease characterized by a variety of symptoms termed COVID-19 disease, with some patients going on to develop post-acute COVID-19 syndrome. Individual factors like sex or coping styles are associated with a person's disease experience and quality of life. Individual differences in coping styles used to manage COVID-19 related stress correlate with physical and mental health outcomes. Our study sought to understand the relationship between COVID-19 symptoms, severity of acute disease, and coping profiles.

METHODS

An online survey to assess symptoms, functional status, and recovery in a large group of patients was nationally distributed online. The survey asked about symptoms, course of illness, and included the Brief-COPE and the adapted Social Relationship Inventory. We used descriptive and cluster analyses to characterize patterns of survey responses.

RESULTS

976 patients were included in the analysis. The most common symptoms reported by the patients were fatigue (72%), cough (71%), body aches/joint pain (66%), headache (62%), and fever/chills (62%). 284 participants reported PACS. We described three different coping profiles: outward, inward, and dynamic copers.

DISCUSSION

Fatigue, cough, and body aches/joint pains were the most frequently reported symptoms. PACS patients were sicker, more likely to have been hospitalized. Of the three coping profiles, outward copers were more likely to be admitted to the hospital and had the healthiest coping strategies. Dynamic copers activated several coping strategies both positive and negative; they were also younger and more likely to report PACS.

CONCLUSION

Cough, fatigue, and body aches/joint pain are common and most important to patients with acute COVID-19, while shortness of breath defined the experience for patients with PACS. Of the three coping profiles, dynamic copers were more likely to report PACS. Additional investigations into coping profiles in general, and the experience of COVID-19 and PACS is needed.

Phenotypic characteristics, healthcare use, and treatment in children with night cough compared with children with wheeze

OBJECTIVES

Population-based studies of children with dry night cough alone compared with those who also wheeze are few and inconclusive. We compared how children with dry night cough differ from those who wheeze.

METHODS

LuftiBus in the school is a population-based study of schoolchildren conducted between 2013 and 2016 in Zurich, Switzerland. We divided children into four mutually exclusive groups based on reported dry night cough (henceforth referred as "cough") and wheeze and compared parent-reported symptoms, comorbidities, exposures, FeNO, spirometry, and healthcare use and treatment.

RESULTS

Among 3457 schoolchildren aged 6-17 years, 294 (9%) reported "cough," 181 (5%) reported "wheeze," 100 (3%) reported "wheeze and cough," and 2882 (83%) were "asymptomatic." Adjusting for confounders in a multinomial regression, children with "cough" reported more frequent colds, rhinitis, and snoring than "asymptomatic" children; children with "wheeze" or "wheeze and cough" more often reported hay fever, eczema, and parental histories of asthma. FeNO and spirometry were similar among "asymptomatic" and children with "cough," while children with "wheeze" or "wheeze and cough" had higher FeNO and evidence of bronchial obstruction. Children with "cough" used healthcare less often than those with "wheeze," and they attended mainly primary care. Twenty-two children (7% of those with "cough") reported a physician diagnosis of asthma and used inhalers. These had similar characteristics as children with wheeze.

CONCLUSION

Our representative population-based study confirms that children with dry night cough without wheeze clearly differed from those with wheeze. This suggests asthma is unlikely, and they should be investigated for alternative aetiologies, particularly upper airway disease.

Predictors of treatment response to pregabalin in unexplained or refractory chronic cough

BACKGROUND

Patients with chronic cough (>8 weeks) often remain symptomatic after appropriate investigations and therapeutic trials. Prior research has shown a benefit in certain individuals from pregabalin, but clinical improvement is quite unpredictable and variable.

OBJECTIVE

The main objective of this study was to identify the demographic and clinical characteristics associated with a higher likelihood of cough improvement with a trial of pregabalin therapy.

METHODS

50 consecutive patients with chronic cough were enrolled in this prospective cohort study. Subjects were prescribed pregabalin 75 mg oral qhs for 4 weeks followed by 75 mg oral bid. Leicester Cough Questionnaire (LCQ) was completed at treatment initiation and after 3 months of therapy. A comparison was performed between treatment responders (LCQ total score improvement ≥1.3) and non-responders.

RESULTS

56% of patients reported a LCQ total score improvement ≥1.3 (minimal clinically important difference). Responders to pregabalin therapy were more likely to have refractory (with underlying pulmonary disease) versus unexplained chronic cough (p = 0.01). Patients with significant improvement were also on average more symptomatic at baseline (mean LCQ total score 10.2 versus 13.0, p < 0.01). No significant relationship was identified with age, gender, body mass index, history of anxiety and/or depression, cigarette smoking history, or cough duration (p > 0.05). The unexplained chronic cough group had a strong female predominance (85.7% versus 40.9% for refractory cough, p < 0.01).

CONCLUSION

This is the first study that has investigated clinical predictors of treatment response to pregabalin in chronic cough patients. Further research is needed to develop therapies for subjects who do not improve with currently available neuromodulating medications.

[Investigation of diagnostic methods and criteria for gastroesophageal reflux-related cough]

Gastroesophageal reflux-related cough is a multidisciplinary disease that cannot be diagnosed solely based on typical reflux-related symptoms. Its current diagnostic methods and criteria are largely derived from those used for gastroesophageal reflux disease, with slight differences. Esophageal reflux monitoring can provide objective evidence for the diagnosis of gastroesophageal reflux-related cough and is therefore the first-choice of laboratory tests recommended by the guidelines for cough management. Acid exposure time and syndrome association probability have been accepted as the diagnostic criteria, while esophageal motility assessment also has some certain auxiliary diagnostic value. Based on the existing evidence, we have reviewed how to improve the diagnostic methods and criteria for gastroesophageal reflux-related cough, as well as the issues that need to be addressed in the future.

Therapeutic thoracentesis symptoms and activity: a qualitative study

INTRODUCTION

Malignant pleural effusions (MPEs) commonly occur in patients with advanced cancer. Drainage of fluid is used to relieve symptoms and improve quality of life.

OBJECTIVE

To improve our understanding of how therapeutic aspiration affects symptoms and activities in patients with MPE.

METHODS

Patients presenting to the Pleural Clinic at Norfolk and Norwich University Hospital with a confirmed or suspected MPE participated in up to three semistructured interviews during their diagnostic/therapeutic pathway. Interviews were analysed using framework analysis by two researchers independently.

RESULTS

Sixteen patients participated. Symptoms reported before drainage included breathlessness, cough, chest pain, fatigue and anorexia. Symptoms affected their activities, including walking, bending over and socialisation. Patients described anxiety about the underlying diagnosis and fear of over-reliance on others. Expectations of drainage outcome varied, with some hoping for a cure and others hoping for any improvement. After drainage, breathlessness, chest pain and cough improved in some patients. They reported feeling and sleeping better, but fatigue and poor appetite remained. Participants were more active after aspiration, but the duration of improvement was a few days only. Despite this, patients still felt the procedure worthwhile.

CONCLUSION

Overall health and respiratory symptoms improved following drainage, but constitutional symptoms did not improve. This may be because constitutional symptoms are caused by the underlying cancer. This study suggests that clinicians should consider a range of symptoms, rather than just breathlessness, in planning outcomes for clinical trials. These results are important to inform patients about the potential benefits and duration of symptom improvement after therapeutic aspiration.

[Can cough peak flow be used to assess cough capacity in severe obstructive respiratory diseases?]

INTRODUCTION

Cough capacity is assessed by measuring cough peak flow (CPF). However, this assessment could be altered by obstructive airway diseases. The aim was to assess measurement of cough capacity by CPF in patients with chronic obstructive pulmonary disease (COPD), as well as correlations with pulmonary, respiratory muscle, and oropharyngeal function.

METHODS

Patients with COPD, and with neuromuscular disease, were selected as well as healthy subjects who had undergone respiratory muscle strength measurement in a healthcare setting. From this population, respiratory function values and lung and oropharyngeal muscle function were analysed. A subgroup of COPD patients underwent a videofluoroscopic swallow study.

RESULTS

Three hundred and seven subjects were included (59.3% COPD, 38.4% neuromuscular diseases, and 2.3% healthy). CPF was found to be statistically significantly decreased in the COPD group compared to both the healthy and neuromuscular disease groups. Of the COPD patients, 70% had a pathological decrease in CPF. There was only a direct correlation between CPF with the degree of bronchial obstruction and expiratory muscle strength. No alteration of inspiratory or oropharyngeal muscle function was found.

CONCLUSIONS

The use of CPF in COPD patients does not reflect cough capacity as it is influenced by the degree of bronchial obstruction. Therefore, new diagnostic tests to measure cough capacity should be considered, especially in patients with coexisting neuromuscular diseases and severe bronchial obstructive disease.

Characterization of changes in the intestinal microbiome following combination therapy with zinc preparation and conventional treatment for children with rotavirus enteritis

Background

Rotavirus (RV) is one of the most common pathogens causing diarrhea in infants and young children worldwide. Routinely, antiviral therapy, intestinal mucosa protection, and fluid supplementation are used in clinic, however this is not efficacious in some severe cases. Zinc supplementation has previously been shown to improve resolution of symptoms from infectious diarrhea.

Methods

In this study differences in response rate, duration of hyperthermia, vomiting, and diarrhea, and the persistence time of cough and lung rales in groups were compared. 16SrDNA gene sequencing technology was used to analyze and compare changes in the intestinal microflora of children with RV enteritis who received the conventional treatment with or without the zinc preparation. In addition, the correlations between the differential bacterial species and the related inflammatory factors were determined.

Results

Conventional therapy combined with the zinc preparation significantly shortened the duration of hyperthermia, vomiting, and diarrhea compared with the conventional treatment alone. In addition, the time to symptom relief showed that the absorption time of cough and lung rales was significantly shorter in the combination treatment group than that in the conventional treatment group in the children with pneumonia. Further, compared with the conventional treatment, the combined treatment significantly increased the diversity and abundances of florae as compared with the conventional treatment. This combination therapy containing zinc preparation markedly increased the abundances of Faecalibacterium, Bacteroidales, Ruminoccoccoccus, and Lachnospiraceae at the genus level. The LEfSe analysis suggested that Clostridiumbolteae were most significantly altered after the combination therapy. In addition, a correlation analysis revealed significantly negative correlations between the inflammatory factors especially IL-6, TNF-a, CRP and some intestinal florae such as Bacteroides, Faecalibacterium, Blautia, Parabacteroides, Subdoligranulum, and Flavonifractor.

Conclusion

Compared with the conventional therapy alone, the combined therapy with the zinc preparation significantly improves symptoms caused by RV. The combination therapy containing the zinc preparation significantly increases the diversity and abundances of some beneficial groups of bacteria. Further, The presence of these groups was further negatively correlated with relevant inflammatory factors. More importantly, this combination therapy containing the zinc preparation provides a reference for the clinical management of children with RV enteritis.

Etiology and clinical features of children with bronchiectasis in China: A 10-year multicenter retrospective study

INTRODUCTION

The current study aims to investigate the etiology spectrum and the clinical characteristics of bronchiectasis in Chinese children.

METHODS

The study is designed as a multicenter retrospective study. 193 cases were enrolled in 13 centers in China between 2008 and 2017. The inclusive cases must meet the clinical as well as the HRCT criteria. Only if both two radiologists confirmed the diagnosis, the case could be enrolled. The cases that could not provide clinical and imageology data were excluded. The data were entered into the specialized system and then analyzed.

RESULTS

One hundred sixty-nine cases (87%) were found to have the underlying etiology. Post-infective (46%), primary immunodeficiency (14%), and PCD (13%) were the common causes. All cases came from 28 provinces in Mainland China. The median age of symptom onset was 5.8 (2.0, 8.9) years. The median age of diagnosis was 8.4 (4.5, 11.6) years. The main symptoms were cough, sputum expectoration, and fever during the exacerbation. Nineteen percent of patients suffered from limited exercise tolerance. Clubbing was found in 17% of cases. Nearly 30% of patients presented growth limitations. On the HRCT findings, 126 cases had diffused bronchiectasis, and bilateral involvement was found in 94 cases. The lower lobes and right middle lobes were most commonly involved. Approximately 30% of cultures of sputum and bronchoalveolar lavage were positive.

CONCLUSION

A majority of cases could be found the underlying etiology. Post-infective, primary immunodeficiency, and PCD were the most common causes. Some clinical figures might indicate a specific etiology.

Chronic Suppurative Lung Disease in Children: A Case Based Approach

Bronchiectasis is a pathologic state of conducting airways manifested radiographically by evidence of bronchial dilation and clinically by chronic productive cough. Considered an "orphan disease" for long, it remains a major contributor to morbidity and mortality in both developed and underdeveloped countries. With the advances in the medical field accompanied by widespread access to vaccines and antibiotics, improved health services and better access to nutrition, the incidences of bronchiectasis have markedly decreased, particularly in developed countries. This review summarizes the current knowledge pertaining to the clinical definition, etiology, clinical approach and management related to pediatric bronchiectasis.

Icenticaftor, a CFTR Potentiator, in COPD: A Multicenter, Parallel-Group, Double-Blind Clinical Trial

Rationale: CFTR (cystic fibrosis transmembrane conductance regulator) dysfunction is associated with mucus accumulation and worsening chronic obstructive pulmonary disease (COPD) symptoms. Objectives: The aim of this phase IIb dose-finding study was to compare a CFTR potentiator, icenticaftor (QBW251), with placebo in patients with COPD and chronic bronchitis. Methods: Patients with COPD on triple therapy for at least three months were randomized to six treatment arms (icenticaftor 450, 300, 150, 75, or 25 mg or placebo twice daily [b.i.d.]) in a 24-week, multicenter, parallel-group, double-blind study. The primary endpoint was change from baseline in trough FEV1 after 12 weeks. Secondary endpoints included change from baseline in trough FEV1 and Evaluating Respiratory Symptoms in COPD (E-RS) total and cough and sputum scores after 24 weeks. Multiple comparison procedure-modeling was conducted to characterize dose-response relationship. Rescue medication use, exacerbations, and change in serum fibrinogen concentration after 24 weeks were assessed in exploratory and post hoc analyses, respectively. Measurements and Main Results: Nine hundred seventy-four patients were randomized. After 12 weeks of icenticaftor treatment, no dose-response relationship for change from baseline in trough FEV1 was observed; however, it was observed for E-RS cough and sputum score. A dose-response relationship was observed after 24 weeks for trough FEV1, E-RS cough and sputum and total scores, rescue medication use, and fibrinogen. A dose of 300 mg b.i.d. was consistently the most effective. Improvements for 300 mg b.i.d. versus placebo were also seen in pairwise comparisons of these endpoints. All treatments were well tolerated. Conclusions: The primary endpoint was negative, as icenticaftor did not improve trough FEV1 over 12 weeks. Although the findings must be interpreted with caution, icenticaftor improved trough FEV1; reduced cough, sputum, and rescue medication use; and lowered fibrinogen concentrations at 24 weeks. Clinical trial registered with www.clinicaltrials.gov (NCT04072887).

Prevalence, clinical presentation and factors associated with chronic lung disease among children and adolescents living with HIV in Kenya

INTRODUCTION

Children and adolescents with HIV (CAHIV) may experience recurrent and severe respiratory disease and are at risk of residual lung sequelae, and long-term morbidity from chronically damaged lungs. With improved survival due to increased access to effective antiretroviral therapy there is an increasing population of CAHIV who require optimal life-long care. Chronic lung disease in CAHIV is an under-recognised problem in African settings. We sought to determine the prevalence, clinical presentation and factors associated with chronic lung disease (CLD) among CAHIV in Kenya.

METHODS

CAHIV aged ≤19 years in care at a public hospital in Nairobi were enrolled into a longitudinal cohort study. Sociodemographic and clinical information were obtained through interview, medical record review, physical examination and six-minute walk test. CD4 counts and viral load were determined. Enrolment data was analysed to determine baseline sociodemographic and clinical characteristics. Prevalence of CLD defined as presence of ≥2 respiratory symptoms or signs at enrolment was computed. Logistic regression analysis was performed to evaluate for association between various factors and presence or absence of CLD.

RESULTS

We enrolled 320 CAHIV of median age 13 (IQR 10-16) years, 80 (25%) were <10 years, 46% were female, 31% lived in a one-room house and 51% used polluting cooking fuel. Antiretroviral therapy (ART) was initiated after age five years in 56%, 43% had prior pneumonia or tuberculosis, 11% had low CD4 count and 79% were virologically suppressed. Common respiratory symptoms and signs were exertional breathlessness (40%), chronic cough (23%), chest problems in the preceding year (24%), tachypnoea (52%), finger clubbing (6%), exercise limitation (59%) and oxygen desaturation during exercise (7%). CLD was present in 82 (26%) participants, and adding the six-minute walk distance <70% of predicted (exercise limitation) identified an additional 28 (9%) CAHIV with CLD. CLD was more common among older teenagers (odds ratio (OR) 1.95), those who had prior TB or pneumonia (OR 2.04), delayed initiation of ART (OR 2.60), cotrimoxazole prophylaxis (OR 3.35) or TB preventive therapy (OR 2.81). CLD was associated with viraemia (OR 2.7), lower quality of life (OR 12.7), small houses (OR 2.05), caregiver having fewer years of education (OR 2.46), outdoor pollution exposure (OR 3.31) and lower use of polluting cooking fuel indoors (OR 0.26). Adjusted analysis revealed CLD to be associated with prior tuberculosis or pneumonia (adjusted OR (aOR) [95%CI] 2.15 [1.18-3.91]), small house (aOR 1.95 [1.02-3.73]), lower use of polluting cooking fuel (aOR 0.35 [0.13-0.94]) and negative impact on health-related quality of life (aOR 6.91 [3.66-13.03]).

CONCLUSIONS

CLD is highly prevalent across the age spectrum of CAHIV, and most are symptomatic with cough or exertional breathlessness. CLD is associated with prior tuberculosis or pneumonia, socio-environmental factors, and lower quality of life. Structured interventions are needed to provide optimal care specific to their needs.

Identifying potentially undiagnosed nontuberculous mycobacterial lung disease among patients with chronic obstructive pulmonary disease: Development of a predictive algorithm using claims data

BACKGROUND: Nontuberculous mycobacterial lung disease (NTMLD) is a debilitating disease. Chronic obstructive pulmonary disease (COPD) is the leading comorbidity associated with NTMLD in the United States. Their similarities in symptoms and overlapping radiological findings may delay NTMLD diagnosis in patients with COPD. OBJECTIVE: To develop a predictive model that identifies potentially undiagnosed NTMLD among patients with COPD. METHODS: This retrospective cohort study developed a predictive model of NTMLD using US Medicare beneficiary claims data (2006 - 2017). Patients with COPD with NTMLD were matched 1:3 to patients with COPD without NTMLD by age, sex, and year of COPD diagnosis. The predictive model was developed using logistic regression modeling risk factors such as pulmonary symptoms, comorbidities, and health care resource utilization. The final model was based on model fit statistics and clinical inputs. Model performance was evaluated for both discrimination and generalizability with c-statistics and receiver operating characteristic curves. RESULTS: There were 3,756 patients with COPD with NTMLD identified and matched to 11,268 patients with COPD without NTMLD. A higher proportion of patients with COPD with NTMLD, compared with those with COPD without NTMLD, had claims for pulmonary symptoms and conditions, including hemoptysis (12.6% vs 1.4%), cough (63.4% vs 24.7%), dyspnea (72.5% vs 38.2%), pneumonia (59.2% vs 13.4%), chronic bronchitis (40.5% vs 16.3%), emphysema, (36.7% vs 11.1%), and lung cancer (15.7% vs 3.5%). A higher proportion of patients with COPD with NTMLD had pulmonologist and infectious disease (ID) specialist visits than patients with COPD without NTMLD (≥ 1 pulmonologist visit: 81.3% vs 23.6%, respectively; ≥ 1 ID visit: 28.3% vs 4.1%, respectively, P < 0.0001). The final model consists of 10 risk factors (≥ 2 ID specialist visits; ≥ 4 pulmonologist visits; the presence of hemoptysis, cough, emphysema, pneumonia, tuberculosis, lung cancer, or idiopathic interstitial lung disease; and being underweight during a 1-year pre-NTMLD period) predicting NTMLD with high sensitivity and specificity (c-statistic, 0.9). The validation of the model on new testing data demonstrated similar discrimination and showed the model was able to predict NTMLD earlier than the receipt of the first diagnostic claim for NTMLD. CONCLUSIONS: This predictive algorithm uses a set of criteria comprising patterns of health care use, respiratory symptoms, and comorbidities to identify patients with COPD and possibly undiagnosed NTMLD with high sensitivity and specificity. It has potential application in raising timely clinical suspicion of patients with possibly undiagnosed NTMLD, thereby reducing the period of undiagnosed NTMLD. DISCLOSURES: Dr Wang and Dr Hassan are employees of Insmed, Inc. Dr Chatterjee was an employee of Insmed, Inc, at the time of this study. Dr Marras is participating in multicenter clinical trials sponsored by Insmed, Inc, has consulted for RedHill Biopharma, and has received a speaker's honorarium from AstraZeneca. Dr Allison is an employee of Statistical Horizons, LLC. This study was funded by Insmed Inc.

Rehabilitation post-COVID-19: cross-sectional observations using the Stanford Hall remote assessment tool

INTRODUCTION

The multisystem COVID-19 can cause prolonged symptoms requiring rehabilitation. This study describes the creation of a remote COVID-19 rehabilitation assessment tool to allow timely triage, assessment and management. It hypotheses those with post-COVID-19 syndrome, potentially without laboratory confirmation and irrespective of initial disease severity, will have significant rehabilitation needs.

METHODS

Cross-sectional study of consecutive patients referred by general practitioners (April-November 2020). Primary outcomes were presence/absence of anticipated sequelae. Binary logistic regression was used to test association between acute presentation and post-COVID-19 symptomatology.

RESULTS

155 patients (n=127 men, n=28 women, median age 39 years, median 13 weeks post-illness) were assessed using the tool. Acute symptoms were most commonly shortness of breath (SOB) (74.2%), fever (73.5%), fatigue (70.3%) and cough (64.5%); and post-acutely, SOB (76.7%), fatigue (70.3%), cough (57.4%) and anxiety/mood disturbance (39.4%). Individuals with a confirmed diagnosis of COVID-19 were 69% and 63% less likely to have anxiety/mood disturbance and pain, respectively, at 3 months.

CONCLUSIONS

Rehabilitation assessment should be offered to all patients suffering post-COVID-19 symptoms, not only those with laboratory confirmation and considered independently from acute illness severity. This tool offers a structure for a remote assessment. Post-COVID-19 programmes should include SOB, fatigue and mood disturbance management.

Predictors of Relapses or Recurrences in Patients With Giant Cell Arteritis: A Medical Records Review Study

OBJECTIVE

Giant cell arteritis (GCA) is the most common systemic vasculitis in individuals aged ≥50 years. Its course is marked by a high relapse rate requiring long-term glucocorticoid use with its inherent adverse effects. We aimed to identify factors associated with relapses or recurrences in GCA at diagnosis.

METHODS

We reviewed the medical records of consecutive patients with GCA diagnosed between 2009 and 2019 and followed for at least 12 months. We recorded their characteristics at onset and during follow-up. Factors associated with relapses or recurrences were identified using multivariable analysis.

RESULTS

We included 153 patients, among whom 68% were female with a median age of 73 (47-98) years and a median follow-up of 32 (12-142) months. Seventy-four patients (48.4%) had at least 1 relapse or recurrence. Headache and polymyalgia rheumatica were the most frequent manifestations of relapses. The first relapse occurred at a median time of 13 months after the diagnosis, with a median dose of 5.5 (0-25) mg/d of glucocorticoids.In multivariable analysis, patients with relapses or recurrences had a higher frequency of cough and scalp tenderness at diagnosis (20.3% vs 5.1%; odds ratio [OR], 4.73; 95% confidence interval [CI], 1.25-17.94; p = 0.022; and 41.9% vs 29.1%; OR, 2.4; 95% CI, 1.07-5.39; p = 0.034, respectively). Patients with diabetes mellitus at diagnosis had fewer relapses or recurrences during follow-up (5.4% vs 19%; OR, 0.24; 95% CI, 0.07-0.83; p = 0.024).

CONCLUSIONS

Cough and scalp tenderness at diagnosis were associated with relapses or recurrences, whereas patients with diabetes experienced fewer relapses or recurrences.

Regional Analgesia for Laparoscopic Cholecystectomy Using Ultrasound-guided Quadratus Lumborum Block or Erector Spinae Block: A Randomized Controlled Trial

BACKGROUND

Postoperative pain increases the incidence of venous thrombosis and respiratory complications, prevents early postoperative ambulation, and prolongs hospital stay. Fascial plane injections such as erector spinae plane (ESP) block and quadratus lumborum (QL) blocks are popular methods for postoperative pain control and reducing opioid consumption.

OBJECTIVES

We aimed to evaluate the analgesic effects of ultrasound-guided ESP versus QL block during laparoscopic cholecystectomy for the reduction of pain and analgesic consumption.

STUDY DESIGN

Prospective, double-blind, single-center, randomized controlled clinical trial.

SETTING

Minia University Hospital, Minia Governorate, Egypt.

METHODS

Patients scheduled for laparoscopic cholecystectomy from April 2019 through December 2019 were randomly allocated into 3 groups. After induction of general anesthesia, Group A received an ESP block, group B received a QL block, and group C didn't receive any block (control). The main outcome was the time to the first analgesic request. Secondary outcomes were the pain intensity measured by the Visual Analog Scale at one, 2, 4, 6, 8, 12, 16, 20, and 24 hours postoperatively at rest and cough. The total analgesic requirement during the first 24 postoperative hours, hemodynamics, and any complications were recorded.

RESULTS

Sixty patients scheduled for elective laparoscopic cholecystectomy were enrolled; the clinical and demographic data were similar in the 3 groups. Groups A and B had lower VAS scores at cough than Group C in the first postoperative 2 hours. Compared to Group C, a higher score was reported at 8, 12, and 16 hours in Group A, and at 8 and 16 hours in Group B. Group B had a higher score at 4 hours than Group A. At rest, Group C showed higher scores than Groups A and B in the first 2 hours, while higher scores were noted at 16 hours in Group A and 12 hours in Group B. Time to first request of analgesia was significantly prolonged in Group A than in Groups B and C (P < 0.001). Our study showed that Groups A and B had lower postoperative analgesic requirements than Group C (P < 0.05).

LIMITATIONS

This study had a small number of patients enrolled.

CONCLUSIONS

Both ESP and QL blocks effectively reduced VAS scores at both cough and rest. There was a decreased total consumption of analgesics in the first postoperative 24 hours with a longer duration of analgesia, which lasted 16 hours in the ESP group and 12 hours in the QL group.

Clinical features and diagnostic value of metagenomic next -generation sequencing in five cases of non-HIV related Pneumocystis jirovecii pneumonia in children

Background

Pneumocystis jirovecii (PJ) is an opportunistic pathogenic fungus, and PJ pneumonia (PJP) is a commonly problem in HIV-positive patients. While PJP is not caused by HIV, it generally advances rapidly and can quickly lead to severe respiratory failure. To improve pediatricians’ understanding of the condition and aid early accurate diagnoses and therapy, we examined the clinical characteristics of five instances of non-HIV related PJP (NH-PJP) in children and the efficacy of metagenomic next-generation sequencing (mNGS) in its diagnosis.

Methods

From January 2020 to June 2022, five children with NH-PJP were admitted to the PICU of the First Affiliated Hospital of Zhengzhou University. We retrospectively summarize the clinical presentation, previous histories, routine laboratory findings, treatment, outcome of regression, and results of mNGS in these five children.

Results

Five male children between the ages of 11 months and 14 years had an acute onset on NH-PJP, three of the children had chest tightness after activity, shortness of breath and paroxysmal dry cough, — and two had high fever and dry cough. All five of the children had several flocculent high-density pictures in both lungs at the beginning of the disease, and lung auscultation revealed coarse breath sounds in both lungs, one of which was accompanied by a modest quantity of dry rales. PJ nuclear sequences were found in one patient and four patients’ blood and alveolar lavage fluid. All five children were treated with Trimethoprim-sulfamethoxazole (TMP-SMX) in combination with Caspofungin and corresponding symptomatic treatment. Four patients were cured and one patient died.

Conclusion

Children commonly encounter an initial exposure to NH-PJP, which manifests as a high fever, dry cough, chest discomfort, dyspnea that worsens over time, fast disease progression, and a high death rate. The clinical presentation of children with PJ infection should be taken into consideration along with the results for diagnose. mNGS has higher sensitivity and a shorter detection period compared to identification of PJP.

Sleep-Disordered Breathing and Chronic Respiratory Infections: A Narrative Review in Adult and Pediatric Population

Sleep-disordered breathing (SDB) comprises different diseases characterized by abnormal respiratory patterns during sleep including obstructive sleep apnea. SDB prevalence and impact in patients with chronic respiratory infections have been only marginally studied. The purpose of this narrative review is to report the prevalence and impact of SDB in chronic respiratory infections, including cystic fibrosis (CF), bronchiectasis and mycobacterial infections, and explore the possible pathophysiological mechanisms. Common pathophysiological mechanisms, underlying SDB onset in all chronic respiratory infections, include inflammation, which plays a central role, chronic nocturnal cough and pain, excessive production of mucous plugs, presence of obstructive and/or restrictive ventilatory impairment, upper airways involvement, and comorbidities, such as alteration of nutritional status. SDB may affect about 50% of patients with bronchiectasis. The severity of the disease, e.g., patients colonized with P. aeruginosa and frequent exacerbators, as well as comorbidities, such as chronic obstructive pulmonary disease and primary ciliary dyskinesia, may impact SDB onset. SDB may also frequently complicate the clinical course of both children and adults with CF, impacting the quality of life and disease prognosis, suggesting that their routine assessment should be incorporated into the clinical evaluation of patients from the first stages of the disease regardless of suggestive symptoms, in order to avoid late diagnosis. Finally, although the prevalence of SDB in patients with mycobacterial infections is uncertain, extrapulmonary manifestations, particularly nasopharyngeal locations, and concomitant symptoms, such as body pain and depression, may act as atypical predisposing factors for their development.

Risk factors for urinary incontinence during pregnancy among nulliparous women in the United Arab Emirates

Urinary incontinence (UI), which affects the quality of life, is associated with different risk factors during pregnancy. We aimed to study the risk factors related to UI during pregnancy among nulliparous women in the UAE. This is a prospective descriptive survey, which included all nulliparous women after the first 24 weeks' gestation from 2012 to 2014 in a teaching hospital in the UAE. Participants were interviewed face-to-face, using a structured and pre-tested questionnaire and divided into 2 groups: those with UI and those without it. Factors which were statistically significant (P < .05) between the 2 groups were entered into an logistic regression backward logistic regression model to define the factors predicting UI. Five hundred one participants were interviewed. UI occurred in 106/501 (21.2%). The 2-sample comparison analysis showed that urinary tract infection (UTI) (47.2% vs 34.4%, P = .018) and its number of attacks (P = .007), chronic cough (28.3% vs 13.9%, P < .001) and chronic constipation (34.9% vs 19%, P < .001) were statistically significant between those who had UI and those who did not. The logistic regression backward logistic regression model showed that the risk factors which predicted UI were chronic constipation (P = .003), chronic cough (P = .008), and the number of UTI attacks (P = .036). UI affects one-fifth of nulliparous women in the UAE. Chronic cough, constipation, and repeated UTI infection, significantly increase the odds of UI during pregnancy. Addressing these risk factors may reduce the risk of UI.

Prevalence of symptomatic pelvic organ prolapse and associated factors in Southern Nations, Nationalities, People's Region referral hospitals, Ethiopia

INTRODUCTION AND HYPOTHESIS

Pelvic organ prolapse is one of the major causes of morbidity among women that affect their quality of life. Despite the severity of the problem, there is limited information in Ethiopia. Therefore, this study was aimed at assessing the prevalence of symptomatic POP and its associated factors.

METHODS

An institution-based cross-sectional study was carried out in the referral hospitals of Southern Nations, Nationalities, People's Region, Ethiopia. Women were initially interviewed about their prolapse symptoms using validated questionnaires, and if they answered yes to one or more of the questions, they were examined by gynecologists using simplified POP quantification. Pelvic examination results and patient-reported symptoms were used to determine symptomatic POP. A multivariate logistic regression analysis model was used to identify factors associated with symptomatic prolapse.

RESULTS

A total of 1,196 respondents were included in this study. The prevalence of symptomatic POP was found to be 20.1%. Age of women ≥55 years (AOR=8.39; 95% CI 3.41-20.62), carrying heavy objects for ≥ 5 h (AOR= 5.18; 95% CI 2.51-10.69), parity ≥4 times (AOR=2.98; 95% CI 1.60-5.53), history of home delivery (AOR= 2.90; 95% CI 1.50-5.61), giving birth through assisted vaginal delivery (AOR=5.01; 95% CI 1.73-14.53), history of chronic constipation (AOR=2.66; 95% CI 1.38-5.15), and a history of a chronic cough (AOR=9.18; 95% CI 4.52-18.61) were associated with symptomatic POP.

CONCLUSIONS

In this study the prevalence of symptomatic POP is high. Older age, long hours of carrying heavy objects, a high parity, last birth through assisted vaginal delivery, a history of home delivery, a history of chronic constipation, and a history of a chronic cough were found to be associated with symptomatic POP.

Association of respiratory symptoms and lung function with occupation in the multinational Burden of Obstructive Lung Disease (BOLD) study

BACKGROUND

Chronic obstructive pulmonary disease has been associated with exposures in the workplace. We aimed to assess the association of respiratory symptoms and lung function with occupation in the Burden of Obstructive Lung Disease study.

METHODS

We analysed cross-sectional data from 28 823 adults (≥40 years) in 34 countries. We considered 11 occupations and grouped them by likelihood of exposure to organic dusts, inorganic dusts and fumes. The association of chronic cough, chronic phlegm, wheeze, dyspnoea, forced vital capacity (FVC) and forced expiratory volume in 1 s (FEV1)/FVC with occupation was assessed, per study site, using multivariable regression. These estimates were then meta-analysed. Sensitivity analyses explored differences between sexes and gross national income.

RESULTS

Overall, working in settings with potentially high exposure to dusts or fumes was associated with respiratory symptoms but not lung function differences. The most common occupation was farming. Compared to people not working in any of the 11 considered occupations, those who were farmers for ≥20 years were more likely to have chronic cough (OR 1.52, 95% CI 1.19-1.94), wheeze (OR 1.37, 95% CI 1.16-1.63) and dyspnoea (OR 1.83, 95% CI 1.53-2.20), but not lower FVC (β=0.02 L, 95% CI -0.02-0.06 L) or lower FEV1/FVC (β=0.04%, 95% CI -0.49-0.58%). Some findings differed by sex and gross national income.

CONCLUSION

At a population level, the occupational exposures considered in this study do not appear to be major determinants of differences in lung function, although they are associated with more respiratory symptoms. Because not all work settings were included in this study, respiratory surveillance should still be encouraged among high-risk dusty and fume job workers, especially in low- and middle-income countries.

Clinical Characteristics and Risk Factors of Polymyositis and Dermatomyositis Combined with Interstitial Lung Disease in Patients Residing in the Northeast Sichuan Province of China

BACKGROUND

Polymyositis (PM) and dermatomyositis (DM) are non-suppurative and autoimmune inflammatory diseases of striated muscle. Interstitial lung disease (ILD) is a group of heterogeneous diseases that mainly involve the pulmonary interstitium, alveoli, and/or bronchioles, also known as diffuse parenchymal lung disease (DPLD). A significant cause of death in persons with polymyositis (PM) and dermatomyositis (DM) is concurrent interstitial lung disease (ILD). However, research on the clinical characteristics and associated influencing factors of PM/DM combined with ILD (PM/DM-ILD) is currently scarce in China.

OBJECTIVE

The study aimed to probe the clinical features and risk factors of PM/DM-ILD.

METHODS

The data of 130 patients with PM/DM were gathered. General medical status, clinical symptoms, laboratory parameters, high-resolution CT, therapeutic outcomes, and prognoses were retrospectively reviewed in patients with PM/DM with (ILD group) and without (NILD) ILD.

RESULTS

The age of the ILD group (n=65) was more than the NILD group (n=65), and the difference was statistically significant; there were no significant between-group variations in the PM/DM ratio, sex, or duration of the disease. The initial symptoms were arthritis and respiratory symptoms in the ILD group, and myasthenia symptoms in the NILD group. Incidences of Raynaud's phenomenon, dry cough, expectoration, dyspnea on exertion, arthritis, fever, total globulin (GLOB), erythrocyte sedimentation rate (ESR), and anti-Jo-1 antibody rate were higher for ILD; however, albumin (ALB), creatine kinase aspartate aminotransferase activity ratio (CK/AST) and CK levels were significantly lower in the ILD group. Bivariate logistic regression analysis showed age, dry cough, arthritis, dyspnea on exertion, anti-Jo-1 antibody, and elevated GLOB to be independent risk factors for ILD among patients with PM/DM.

CONCLUSION

Advanced age, dry cough, arthritis, dyspnea on exertion, anti-Jo-1 antibody positivity, and elevated GLOB level are risk factors for PM/DM-ILD. This information could be utilized to carefully monitor changing lung function in these patients.

Association between early respiratory viral infections and structural lung disease in infants with cystic fibrosis

BACKGROUND

Infants with cystic fibrosis (CF) develop structural lung disease early in life, and viral infections are associated with progressive lung disease. We hypothesized that the presence of respiratory viruses would be associated with structural lung disease on computed tomography (CT) of the chest in infants with CF.

METHODS

Infants with CF were enrolled before 4 months of age. Multiplex PCR assays were performed on nasal swabs to detect respiratory viruses during routine visits and when symptomatic. Participants underwent CT imaging at approximately 12 months of age. Associations between Perth-Rotterdam Annotated Grid Morphometric Analysis for CF (PRAGMA-CF) CT scores and respiratory viruses and symptoms were assessed with Spearman correlation coefficients.

RESULTS

Sixty infants were included for analysis. Human rhinovirus was the most common virus detected, on 28% of tested nasal swabs and in 85% of participants. The median (IQR) extent of lung fields that was healthy based on PRAGMA-CF was 98.7 (0.8)%. There were no associations between PRAGMA-CF and age at first virus, or detection of any virus, including rhinovirus, respiratory syncytial virus, or parainfluenza. The extent of airway wall thickening was associated with ever having wheezed (ρ = 0.31, p = 0.02) and number of encounters with cough (ρ = 0.25, p = 0.0495).

CONCLUSIONS

Infants with CF had minimal structural lung disease. We did not find an association between respiratory viruses and CT abnormalities. Wheezing and frequency of cough were associated with early structural changes.

Cough-Specific Quality of Life Predicts Disease Progression Among Patients With Interstitial Lung Disease: Data From the Pulmonary Fibrosis Foundation Patient Registry

BACKGROUND

Cough is a common symptom of interstitial lung disease (ILD) and negatively impacts health-related quality of life (QOL). Previous studies have shown that among patients with idiopathic pulmonary fibrosis, cough may predict progression of lung disease and perhaps even respiratory hospitalizations and mortality.

RESEARCH QUESTION

Does cough-specific QOL predict disease progression, respiratory hospitalization, lung transplantation, and death among patients with ILD?

STUDY DESIGN AND METHODS

We analyzed data from the Pulmonary Fibrosis Foundation Registry, which comprises a multicenter population of well-characterized patients with ILD. We first examined associations between patient factors and baseline scores on the Leicester Cough Questionnaire (LCQ), a cough-specific QOL tool, using a proportional odds model. Next, we examined associations between baseline LCQ scores and patient-centered clinical outcomes, as well as pulmonary function parameters, using a univariable and multivariable proportional hazards model that was adjusted for clinically relevant variables, including measures of disease severity.

RESULTS

One thousand four hundred forty-seven patients with ILD were included in our study. In the multivariable proportional odds model, we found that the following patient factors were associated with worse cough-specific QOL: younger age, diagnosis of "other ILD," gastroesophageal reflux disease, and lower FVC % predicted. Multivariable Cox regression models, adjusting for several variables including baseline disease severity, showed that a 1-point decrease in LCQ score (indicating lower cough-specific QOL) was associated with a 6.5% higher risk of respiratory-related hospitalization (hazard ratio [HR], 1.065; 95% CI, 1.025-1.107), a 7.4% higher risk of death (HR, 1.074; 95% CI, 1.020-1.130), and an 8.7% higher risk of lung transplantation (HR, 1.087; 95% CI, 1.022-1.156).

INTERPRETATION

Among a large population of well-characterized patients with ILD, cough-specific QOL was associated independently with respiratory hospitalization, death, and lung transplantation.

High prevalence and clinical characteristics of respiratory infection by human rhinovirus in children from Lima-Peru during years 2009–2010

Introduction

Human rhinovirus is a major cause of acute respiratory infections (ARIs) worldwide. Epidemiological data on human rhinovirus (RV) in Peru is still scarce, as well as its role in respiratory infections in children. Therefore, the aim of this study was to describe the prevalence of rhinovirus and to identify the circulating species in nasopharyngeal swabs from children with acute respiratory infections.

Materials and methods

We analyzed nasopharyngeal swab samples that were collected from children younger than 17 years old, who had a clinical diagnosis of ARI from the “Hospital Nacional Cayetano Heredia” between May 2009 and December 2010. The original study recruited 767 inpatients with ARI, 559 samples of which were included and analyzed in the current study. Detection of rhinovirus and determination of rhinovirus species were characterized by PCR.

Results

Rhinovirus was detected in 42.22% samples (236/559), RV-A was detected in 10.17% (24/236) of the cases, RV-B in 16.53% (39/236), and RV-C in 73.31% (173/236). The age group with the highest number of cases was the 0–5 months group with 45.97%, followed by the 1–5 years group with 25.22%. Most of the positive RV cases, i.e., 86.44% (204/236), were hospitalized. The most common signs and symptoms found in patients who tested positive for RV were cough (72.88%), fever (68.64%), rhinorrhea (68.22%), and respiratory distress (61.44%). Infection with RV-A was associated with wheezing (p = 0.02). Furthermore, RV-C was related to cough (p = 0.01), wheezing (p = 0.002), and conjunctival injection (p = 0.03). A peak in RV-C cases was found in March (32 cases in 2010); June (18 cases in 2009 and 12 cases in 2010), which corresponds to the fall season in Peru; and also November (17 cases in 2009 and 4 cases in 2010), which corresponds to spring. RV-A and RV-B cases were constant throughout the year.

Conclusion

In conclusion, we found a high prevalence of rhinovirus C infection among pediatric patients with acute respiratory infections in Lima, Peru. This viral infection was more common in children between 0 to 5 months old, and was associated with cough, wheezing, and conjunctival injection. Epidemiological surveillance of this virus should be strengthened/encouraged in Peru to determine its real impact on respiratory infections.

Imaging findings of vertebral osteomyelitis caused by nontuberculous mycobacterial organisms: Three case reports and literature review

RATIONALE

Prompt diagnosis of nontuberculous Mycobacterial (NTM) vertebral osteomyelitis is challenging, yet necessary to prevent serious morbidity and mortality. Here, we report 3 cases of vertebral osteomyelitis caused by NTM with imaging findings.

PATIENT CONCERNS

Case 1, a 58-year-old male patient, was admitted to our hospital because of the presence of a pulmonary mass for 6 months with cough and chest pain.Case 2, a 50-year-old male patient, had fever and cough for 3 years and was diagnosed with tuberculosis. Antituberculosis treatment was ineffective, accompanied by lymph node enlargement and osteosclerotic changes involving vertebral bodies.Case 3, a 66-year-old female patient, was admitted to our hospital with a mass on the top of her head for 1 month, which ruptured in the last 2 weeks.

DIAGNOSES

Case 1: Sputum culture revealed Mycobacterium (M.) avium.Case 2: The final culture results of the lymph node biopsy samples were M. intracellulare.Case 3: Culture results of the sputum and pus from the abscess were M. gordon.We found sclerosing lesions in the spine in all 3 NTM patients, which were easily misdiagnosed as metastatic tumors. In 2 cases, there was bone destruction in the ilium with limbic sclerosis, and there were abscesses near the ilium and in front of the sacrum in 1 case.

INTERVENTIONS

Case 1 was transferred to other specialist hospital.Case 3 received surgical treatment for cranial lesions and abscess drainage.Case 2 and case 3 received targeted treatment for nontuberculous mycobacteria in our hospital.

OUTCOME

The condition of case 1 was unknown.Recovery of case 2 was uneventful because of prolonged illness; however, inflammation gradually improved overall.Case 3 had no recurrence following surgical treatment.

LESSONS

In our 3 cases of NTM vertebral osteomyelitis, bone lesions were often misdiagnosed as bony metastases because of the presence of multiple sclerotic lesions. Diagnoses were challenging and delayed. It is important to consider osteomyelitis by NTM when disseminated osteosclerosis with or without osteolytic bone lesions is present in conjunction with continuous inflammatory symptoms and signs. Moreover, an open biopsy of the lesion should be performed for a definitive diagnosis.

Effect of airway clearance therapies on mucociliary clearance in adults with cystic fibrosis: A randomized controlled trial

BACKGROUND

Cystic fibrosis (CF) is an inherited disorder causing impaired mucociliary clearance within the respiratory tract, and is associated with bronchiectasis, chronic respiratory infections, and early death. Airway clearance therapies have long been a cornerstone of management of individuals with CF, although evidence supporting their use is lacking. We designed a randomized controlled trial to quantitatively compare the effects of different forms of airway clearance on mucociliary clearance.

METHODS

Three different physiotherapy methods to augment cough-clearance were studied in addition to cough-clearance alone: high-frequency chest-wall oscillating vest, oscillatory positive expiratory pressure, and whole-body vibration. We used gamma scintigraphy after inhalation of radiolabeled particles to quantify mucus clearance before, during, and after physiotherapy. As secondary endpoints, we measured concentrations of small molecules in exhaled breath that may impact mucus clearance.

RESULTS

Ten subjects were enrolled and completed study procedures. No differences were identified between any method of airway clearance, including cough clearance alone. We did identify changes in certain small molecule concentrations in exhaled breath following airway clearance.

CONCLUSIONS

Due to the limitations of this study, we do not believe the negative results suggest a change in clinical practice with regard to airway clearance. Findings pertaining to small molecules in exhaled breath may serve as future opportunities for study.

Clinical evaluation of a new rapid immunochromatographic test for detection of Bordetella pertussis antigen

A more rapid and less complicated test to diagnose pertussis is required in clinical settings. We need to detect Bordetella pertussis, which mainly causes pertussis, as early as possible, because pertussis is more likely to become severe in infants, and people around them can easily become a source of infection due to its strong infectivity. Nevertheless, methods that can detect B. pertussis rapidly and efficiently are lacking. Therefore, we developed a new immunochromatographic antigen kit (ICkit) for the early diagnosis of pertussis. The ICkit detects B. pertussis antigens in a nasopharyngeal swab without equipment and provides the result in about 15 min with a simple procedure. Additionally, a prospective study to evaluate the ICkit was conducted in 11 medical institutions, involving 195 cases with suspected pertussis. Compared with the real-time polymerase chain reaction (rPCR), the sensitivity and specificity of the ICkit were 86.4% (19/22) and 97.1% (168/173), respectively. The ICkit detected the antigen in both children and adults. Furthermore, the ICkit detected the antigen until the 25th day from the onset of cough, when rPCR detected the antigen. Thus, the ICkit demonstrated a high correlation with rPCR and would help diagnose pertussis more rapidly and efficiently.

Respiratory symptoms and use of dust-control measures in New Zealand construction workers – A cross-sectional study

Dust-exposed construction workers have an increased risk of respiratory symptoms, but the efficacy of dust-control measures remains unclear. This study compared respiratory symptoms, using a modified European Community Respiratory Health Survey questionnaire, between construction workers (n = 208) and a reference group of bus drivers and retail workers (n = 142). Within the construction workers, we assessed the effect of collective (on-tool vacuum/’wet-cut’ systems) and personal (respirators) exposure controls on symptom prevalence. Logistic regression assessed differences between groups, adjusted for age, ethnicity, and smoking status. Construction workers were more likely to cough with phlegm at least once a week (OR 2.4, 95% CI 1.2–4.7) and cough with phlegm ≥3 months/year for ≥2 years (OR 2.8, CI 1.2–7.0), but they had similar or fewer asthma symptoms. Construction workers who had worked for 11–20 years reported more cough/phlegm symptoms (OR 5.1, 1.7–15.0 for cough with phlegm ≥3 months/year for ≥2 years) than those who had worked <10 years (OR 1.9, 0.6–5.8), when compared to the reference group. Those who used ‘wet-cut’ methods reported less cough with phlegm, although the evidence for this association was weak (OR 0.4, CI 0.2–1.1 for cough with phlegm at least once a week); use of on-tool extraction showed a similar trend. No associations between respiratory protective equipment-use and symptoms were found. In conclusion, construction workers reported more symptoms suggestive of bronchitis, particularly those employed in the industry for >10 years. Use of collective dust exposure controls might protect against these symptoms, but this requires confirmation in a larger study.

Romanian Guidelines for the Diagnosis and Treatment of GERD-induced Respiratory Manifestations

BACKGROUND AND AIMS

Gastroesophageal reflux disease (GERD) is a common condition present in daily practice with a wide range of clinical phenotypes. In this line, respiratory conditions may be associated with GERD. The Romanian Societies of Gastroenterology and Neurogastroenterology, in association with the Romanian Society of Pneumology, aimed to create a guideline regarding the epidemiology, diagnosis and treatment of respiratory conditions associated with GERD.

METHODS

Delphi methodology was used and eleven common working groups of experts were created. The experts reviewed the literature according to GRADE criteria and formulated 34 statements and recommendations. Consensus (>80% agreement) was reached for some of the statements after all participants voted.

RESULTS

All the statements and the literature review are presented in the paper, together with their correspondent grade of evidence and the voting results. Based on >80% voting agreement, a number of 22 recommendations were postulated regarding the diagnosis and treatment of GERD-induced respiratory symptoms. The experts considered that GERD may cause bronchial asthma and chronic cough in an important number of patients through micro-aspiration and vagal-mediated tracheobronchial reflex. GERD should be suspected in patients with asthma with suboptimal controlled or after exclusion of other causes, also in nocturnal refractory cough which needs gastroenterological investigations to confirm the diagnosis. Therapeutic test with double dose proton pump inhibitors (PPI) for 3 months is also useful. GERD induced respiratory conditions are difficult to treat; however,proton pump inhibitors and laparoscopic Nissen fundoplication are endorsed for therapy.

CONCLUSIONS

This guideline could be useful for the multidisciplinary management of GERD with respiratory symptoms in current practice.

Nontubercular mycobacterial cough

SummaryHabitual cough suppression leading to non-tuberculous mycobacteria infections and bronchiectasis has been reported. We present a case of a 55-year-old woman with a chronic history of cough with mild expectoration and frequent lower respiratory tract infections, remitting with antibiotic therapy and other supportive measures. She also reported habitual cough suppression for several years. She was eventually diagnosed with Mycobacterium avium complex (MAC) positive right middle lobe bronchiectasis-Lady Windermere syndrome and obstructive sleep apnoea (OSA), causing disabling symptoms limiting her daily activities. We aim to highlight two key issues-diagnosing MAC infections in a tuberculosis endemic country, and OSA and its long-term clinical implications.

[Capacity of vibroacoustic therapy for correction of respiratory manifestations of post COVID-19 syndrome]

The search for therapeutic strategies for the correction of post COVID-19 syndrome is an urgent task of medicine. One of the frequent manifestations of post COVID-19 syndrome is the prolonged persistence of respiratory syndromes - dyspnea and cough. Vibroacoustic therapy is promising methods in the complex effect on broncho-pulmonary symptoms of COVID-19.

OBJECTIVE

To study the effect of vibroacoustic pulmonary therapy implemented through the BARK VibroLUNG apparatus on the clinical and instrumental parameters of patients undergoing COVID-19 with residual respiratory symptoms.

MATHERIAL AND METHODS

The effect of vibroacoustic therapy (5-day course of 2 sessions) on dyspnea and cough and respiratory function in 60 patients aged 18 to 75 years who underwent COVID-19 of varying severity for more than 12 weeks before the start of the study, with the presence of distant respiratory symptoms, was investigated. Patients were divided into two equal and age-matched groups - without (1^st) and with (2^nd) chronic bronchopulmonary pathology.

RESULTS

Analysis of comorbidity of patients with respiratory phenotype of post COVID-19 syndrome showed frequent presence of concomitant cardiovascular pathology (76.7%). The predominant patient complaint was dyspnea (93.3% in both groups): 29 patients (96.7%) in the non-lung group, and 27 patients (90%) in the chronic lung group. The mean mMRC dyspnea score for all patients was 1.1±0.49 points (1.2±0.5 points in the first group and 1.0±0.45 points in the second group). Cough was observed less often - in 18 patients of both groups (30%), mainly in the second group. During the course of vibroacoustic therapy in the 1^st group, the number of patients with dyspnea decreased from 96.7 to 30%, in the 2^nd group - from 90 to 10%, the total mean mMRC dyspnea score decreased to 0.2±0.4 (Δ 82%), and a complete regression of cough syndrome was achieved in both groups. Also, an increase in forced expiratory volume in 1^st second and peak expiratory flow indicators was revealed both in the general group of patients and in the group of patients without chronic lung pathology.

CONCLUSION

The results obtained during the study of the use of vibroacoustic therapy in patients with respiratory manifestations of post-COVID syndrome, including the presence of chronic bronchopulmonary pathology, allow us to conclude on the effective correction of dyspnea and cough during treatment. Vibroacoustic therapy is a promising non-drug method of exposure to bronchopulmonary manifestations of post-COVID syndrome in patients during rehabilitation.

Other Primary Headache Disorders

PURPOSE

This article provides an overview of a diverse group of primary headache disorders that are categorized in the International Classification of Headache Disorders, 3rd Edition (ICHD-3), as "other primary headache disorders." This article provides clinicians with a distilled understanding of the diagnoses and their epidemiology, pathophysiology, and management.

RECENT FINDINGS

Cough-induced headache requires neuroimaging to exclude posterior fossa pathology and recently has been reported as a common symptom in patients with CSF-venous fistula. Clinical overlap is observed between patients with primary exercise headache and primary headache associated with sexual activity. Patients with recurrent thunderclap headache associated with sexual activity should be presumed to have reversible cerebral vasoconstriction syndrome until proven otherwise. De novo external-pressure headache is a common sequela among health care workers using personal protective equipment during the COVID-19 pandemic. New daily persistent headache is an important mimicker of chronic migraine or chronic tension-type headache and is distinguished by a daily-from-onset progression of persistent headache; a treatment-refractory course is often observed, and early involvement of a multidisciplinary team, including a psychotherapist, is advised.

SUMMARY

Patients with primary headache disorders that are classified as "other primary headache disorders" have presentations with unique diagnostic and management considerations. The disorders are highly recognizable, and an appreciation of the diagnoses will aid clinicians in providing safe and effective care for patients presenting with headache.

Epidemiological, clinical, and laboratory findings for patients of different age groups with confirmed coronavirus disease 2019 (COVID-19) in a hospital in Saudi Arabia

BACKGROUND

Although the coronavirus disease 2019 (COVID-19) pandemic continues to rage worldwide, clinical and laboratory studies of this disease have been limited in many countries. We investigated the epidemiologic, clinical, and laboratory findings of COVID-19 infected patients to identify the effective indicators correlated with the disease.

METHODS

A retrospective study was conducted at King Abdullah Hospital in Bisha Province, Saudi Arabia, from March 20 to June 30, 2020. Patients of different age groups were confirmed as having COVID-19 infection using a real-time polymerase chain reaction. The demographic, clinical, and laboratory data of the patients were statistically analyzed.

RESULTS

Of the 132 patients, 85 were male and 47 were female, with a mean age of 50.9 years (SD±16.7). The patients were elderly (n = 29) and adults (n = 103). Of these, 54 (40.9%) had comorbidities, (25%) were admitted to the intensive care unit (ICU), and 12 (9.1%) died. On admission, the main clinical manifestations were fever (84.1%), cough (64.4%), shortness of breath (25%), chest pain (20.5%), and fatigue (18.2%). In all patients, increased neutrophils and decreased lymphocytes were observed. Patients' lactate dehydrogenase (LDH) was elevated. C-reactive protein (CRP) was elevated in 48.5%, D-dimer in 43.2%, and the erythrocyte sedimentation rate (ESR) in 40.9% of patients. The elderly showed higher neutrophil (p = 0.011) and lower lymphocyte (p = 0.009) counts than adults. Glucose, creatine kinase-MB, LDH, bilirubin, D-dimer, and ESR were significantly higher in the elderly than in the adults. The COVID-19 death group had a higher leucocyte count (p = 0.036), and higher urea (p = 0.029) and potassium (p = 0.022) than the recovered group but had a lower hemoglobin concentration (p = 0.018). A significant association was determined between COVID-19 death and the presence of cardiovascular disease (χ2(1) = 16.297, p<0.001), hypertension (χ2(1) = 12.034, p = 0.001), renal failure (χ2(1) = 3.843, p = 0. 05), old age (t (130) = 4.9, p <0.001), and ICU admission (χ2(1) = 17.6 (1), p<0.001).

CONCLUSIONS

Investigating some of the laboratory and clinical parameters could help assess the disease progression, risk of mortality, and follow up patients who could progress to a fatal condition.

Aerosol Exposure During Surgical Tracheotomy in SARS-CoV-2 Positive Patients

INTRODUCTION

Since December 2019, the novel coronavirus SARS-CoV-2 has been spreading worldwide. Since the main route of infection with SARS-CoV-2 is probably via contact with virus-containing droplets of the exhaled air, any method of securing the airway is of extremely high risk for the health care professionals involved. We evaluated the aerosol exposure to the interventional team during a tracheotomy in a semiquantitative fashion. In addition, we present novel protective measures.

PATIENTS AND METHODS

To visualize the air movements occurring during a tracheotomy, we used a breathing simulator filled with artificial fog. Normal breathing and coughing were simulated under surgery. The speed of aerosol propagation and particle density in the direct visual field of the surgeon were evaluated.

RESULTS

Laminar air flow (LAF) in the OR reduced significantly the aerosol exposure during tracheostomy. Only 4.8 ± 3.4% of the aerosol was in contact with the surgeon. Without LAF, however, the aerosol density in the inspiratory area of the surgeon is 10 times higher (47.9 ± 10.8%, P < 0.01). Coughing through the opened trachea exposed the surgeon within 400 ms with 76.0 ± 8.0% of the aerosol-independent of the function of the LAF. Only when a blocked tube was inserted into the airway, no aerosol leakage could be detected.

DISCUSSION

Coughing and expiration during a surgical tracheotomy expose the surgical team considerably to airway aerosols. This is potentially associated with an increased risk for employees being infected by airborne-transmitted pathogens. Laminar airflow in an operating room leads to a significant reduction in the aerosol exposure of the surgeon and is therefore preferable to a bedside tracheotomy in terms of infection prevention. Ideal protection of medical staff is achieved when the procedure is performed under endotracheal intubation and muscle relaxation.

Neurological features and outcome in COVID-19: dementia can predict severe disease

The COVID-19 pandemic has infected more than 22 million people worldwide. Although much has been learned about COVID-19, we do not know much about its neurological features and their outcome. This observational study was conducted on the patients of Imam Hossein Hospital, and 361 adult patients (214 males) with confirmed diagnosis of COVID-19 from March 5, 2020 to April 3, 2020, were enrolled. Data was gathered on age, sex, comorbidities, initial symptoms, symptoms during the disease course, neurological symptoms, and outcome. The mean age of the patients was 61.90 ± 16.76 years. The most common initial symptoms were cough, fever, and dyspnea. In 21 patients (5.8%), the initial symptom was neurological. History of dementia was associated with severe COVID-19 disease (odds ratio = 1.28). During the course of the disease, 186 patients (51.52%) had at least one neurological symptom, the most common being headache (109 [30.2%]), followed by anosmia/ageusia (69, [19.1%]), and dizziness (54, [15%]). Also, 31 patients had neurological complications (8.58%). Anosmia, ageusia, dizziness, and headache were associated with favorable outcome (P < 0.001), while altered mental status and hemiparesis were associated with poor outcome. The mortality rate of patients who had neurological complications was more than twice than that of patients without neurological complication (P = 0.008). Almost half of the patients experienced at least one neurological symptom, which may be the initial presentation of COVID-19. Dementia appears to be associated with severe COVID-19. Mortality was higher in patients with neurological complications, and these patients needed more intensive care.

Effect of pelvic floor electrical stimulation on diaphragm excursion and rib cage movement during tidal and forceful breathing and coughing in women with stress urinary incontinence: A randomized controlled trial

BACKGROUND

The pelvic floor muscle (PFM) is associated with respiratory function. We investigated the effects of PFM training by pelvic floor electrical stimulation (PFES) on PFM strength, diaphragm excursion, and upper rib cage movement during tidal and forceful breathing and coughing in women with stress urinary incontinence (SUI).

METHODS

In total, 33 participants with SUI were divided into PFES and control groups. The two groups were measured pre- and post-8 weeks of training. Diaphragm excursion and upper rib cage movement during tidal and forceful breathing and coughing and PFM strength were measured using sonography, electromagnetic sensors, and perineometry.

RESULTS

There were significant difference of main effect between pre- and post-training and between groups in PFM strength (between groups: P = .001, between time: P < .001) and diaphragm excursion during forceful breathing (between groups: P = .015, between time: P = .026) and coughing (between groups: P = .035, between time: P = .006). There were significant differences in diaphragm excursion during tidal (P = .002) and forceful breathing (P = .005) and coughing (P < .001) between pre- and post-training in the PFES group. Elevation of the upper rib cage during tidal (P < .001) and forceful breathing (P = .001) was significantly decreased after 8 weeks of training in the PFES group. Widening in the horizontal plane in the upper rib cage during forceful breathing (P < .001) was significantly increased after 8 weeks of training in the PFES group. PFM strength (P < .001) was significantly increased after 8 weeks of training in the PFES group.

CONCLUSIONS

Pelvic floor muscles training by electrical stimulation can improve diaphragm excursion and breathing patterns in women with SUI.

20-year-old man • sudden-onset chest pain • worsening pain with cough and exertion • Dx?

► Sudden-onset chest pain ► Worsening pain with cough and exertion ► No improvement with naproxen.