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Oxidative stress has been implicated in the adult respiratory distress syndrome (ARDS). In this study, we determined the levels of selected antioxidants in the plasma of 25 patients with ongoing ARDS and 16 healthy control subjects. We... more
Oxidative stress has been implicated in the adult respiratory distress syndrome (ARDS). In this study, we determined the levels of selected antioxidants in the plasma of 25 patients with ongoing ARDS and 16 healthy control subjects. We also examined these plasmas and pulmonary edema fluid of ARDS patients for lipid hydroperoxides. Both ascorbate and ubiquinol-10 concentrations in ARDS plasma were significantly lower than in normal plasma. alpha-Tocopherol concentrations, when standardized to total plasma cholesterol, were not lower in ARDS patients than in normal subjects. A pattern of antioxidant levels virtually identical to that observed in ARDS plasma was obtained after in vitro incubation of healthy plasma with stimulated polymorphonuclear leukocytes: very low ascorbate, decreased ubiquinol-10, and unchanged alpha-tocopherol concentrations. Nanomolar concentrations of lipid hydroperoxides were found in pulmonary edema fluid of ARDS patients, but not in plasma, nor in the plasma of healthy individuals, when a sensitive and selective chemiluminescence assay for hydroperoxides was used. ARDS patients also showed significant decreases in plasma levels of cholesterol esters in conjunction with discoidal high-density lipoprotein profiles, indicating a decrease in lecithin-cholesterol acyltransferase activity. We conclude that ARDS is associated with oxidative stress, possibly exerted by oxidants released from activated phagocytic leukocytes, and major changes in plasma cholesterol metabolism.
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Research Interests: Medicine and Spirometry
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Antioxidants present within lung epithelial lining fluids (ELFs) constitute an initial line of defense against inhaled environmental oxidants such as ozone, nitrogen oxides, and tobacco smoke, but the antioxidant composition of human ELFs... more
Antioxidants present within lung epithelial lining fluids (ELFs) constitute an initial line of defense against inhaled environmental oxidants such as ozone, nitrogen oxides, and tobacco smoke, but the antioxidant composition of human ELFs is still incompletely characterized. We analyzed ELF concentrations of the low-molecular-mass antioxidants ascorbate, urate, glutathione (GSH), and α-tocopherol by obtaining bronchoalveolar lavage (BAL) and nasal lavage fluids from healthy nonsmoking volunteers and compared two different BAL procedures. ELF dilution by the lavage procedures was estimated by measurement of urea in recovered BAL fluids in comparison with those in blood plasma from the same subjects. The results indicated that a recently developed single-cycle BAL procedure minimizes influx of non-ELF urea into the instilled fluid and thus allows for a more accurate determination of ELF antioxidant concentrations. Using this procedure, we determined that bronchoalveolar ELF contains 4...
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The primary categories of pain are nociceptive and neuropathic. The assessment should focus on understanding the category, cause, and additional emotional and environmental factors that relate to the patients’s pain. Nociceptive pain is... more
The primary categories of pain are nociceptive and neuropathic. The assessment should focus on understanding the category, cause, and additional emotional and environmental factors that relate to the patients’s pain. Nociceptive pain is usually very responsive to opioids and NSAIDS. Neuropathic pain may respond better to antidepressants, anticonvulsants, antiarrhythmics, and sympatholytics. Treatment of related emotional and environmental factors will improve outcomes. Examining coexisting medical and psychosocial conditions can help to prevent poor outcomes and complications. Careful taking of the history and performance of the physical examination should provide the critical diagnostic information. Pain medications have considerable potential for side effects and drug interactions. It is important to obtain careful medication histories. The evaluation should include a screening assessment of the patient’s psychological state, which can uncover signs that more formal pscyhological assessment is needed. Misdiagnosis of brochial asthma is common in adults. Remember bronchial asthma is a heterogenous group of chronic lung disorders characterized by common nonspecific signs and symptoms. Different types of asthma will require diffeent treatments. Clinical overlap with other co-existing conditions, e.g. COPD chronic sinusitis, gastroesophageal reflux disease in common. Asthma patient education is fundamental to an effective treatment and management program. Control of airway inflammation, avoidance of environmental triggers, and individualized pharmacological interventions are essential. Failure to properly manage the inflammatory component of asthma risks increases patient morbidity amd mortality. Prevent acute asthmas exacerbations by controlling triggers and encouraging compliance with controller medications. Women with persistent asthma are at significantly higher risks for developing acute severe exacerbations compared to men. Keep exacerbations as far apart as possible. The key to reducing ashtma morbidity and mortality is prevention. Patient asthma action plans utilizing peak flow monitoring and a combination of controller(s) and reliever drugs to prevent and ameliorate attracks are proven treatment strategies. Personalized treatment plans improve compliance. Consider referring patients who are hospitalized for asthma exacerbations and those with difficult to control asthma to a consultant and/or a pulmonary rehabilitation program. The treatment of elderly adults and pregnant women with asthma differs significantly from that of younger adults. Potential for drug interactions and is greater in the elderly with co-existing medical conditions. The majority of asthma deaths are preventable. Undertreatment of asthma poses a greater risk for death than overtreatment.
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ABSTRACT Mediastinal tumors are comprised of various benign and malignant neoplasms that share the same anatomic location within the thorax. The mediastinum is traditionally divided into three compartments: the anterior, middle, and... more
ABSTRACT Mediastinal tumors are comprised of various benign and malignant neoplasms that share the same anatomic location within the thorax. The mediastinum is traditionally divided into three compartments: the anterior, middle, and posterior mediastinum. This division, based on lateral chest radiographs, helps clinicians establish appropriate differential diagnoses and plan further imaging, diagnostic, and treatment strategies. With the continued and complex advances in imaging, medical treatment, and surgery, we recommend a multidisciplinary approach to the management of mediastinal tumors. This discussion is intended to guide the pulmonary specialist through this potentially complex approach.
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The prognosis and response to therapy of metastases to the lungs are variable and highly dependent on the origin of the primary tumor and on the extent and pattern of spread. Due to the complex pathogenesis underlying the development of... more
The prognosis and response to therapy of metastases to the lungs are variable and highly dependent on the origin of the primary tumor and on the extent and pattern of spread. Due to the complex pathogenesis underlying the development of pulmonary metastases, specific tumor types often display characteristic clinical and radiographic patterns. Understanding these concepts is of paramount importance when planning a diagnostic work-up for patients with possible pulmonary metastases. This review presents state of the art strategies in imaging, medical therapy, and surgery. It should provide the busy pulmonologist with the information needed to devise safe and efficient diagnostic and treatment strategies for patients with pulmonary metastases of extrathoracic origin.
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Pulmonary eosinophilic syndromes include a heterogeneous group of disorders. They have in common the presence of eosinophils in the airways and/or lung parenchyma. They may manifest peripheral eosinophilia and symptoms vary depending on... more
Pulmonary eosinophilic syndromes include a heterogeneous group of disorders. They have in common the presence of eosinophils in the airways and/or lung parenchyma. They may manifest peripheral eosinophilia and symptoms vary depending on what additional organs may be involved. The following cases highlight pulmonary eosinophilic syndromes as conundrums and emphasize a systematic approach to this heterogeneous group of disorders.
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Nitrogen dioxide (NO*2) is often present in inhaled air and may be generated in vivo from nitric oxide. Exposure of human blood plasma to NO*2 caused rapid losses of ascorbic acid, uric acid and protein thiol groups, as well as lipid... more
Nitrogen dioxide (NO*2) is often present in inhaled air and may be generated in vivo from nitric oxide. Exposure of human blood plasma to NO*2 caused rapid losses of ascorbic acid, uric acid and protein thiol groups, as well as lipid peroxidation and depletions of α‐tocopherol, bilirubin and ubiquinol‐10. No increase in protein carbonyls was detected. Supplementation of plasma with ascorbate decreased the rates of lipid peroxidation. α‐tocopherol depletion and loss of uric acid. Uric acid supplementation decreased rates of lipid peroxidation but not the loss of α‐tecopherol. We conclude that ascorbic acid, protein ‐SH groups, uric acid and α‐tocopherol may be important agents protecting against NO*2 in vivo. If these antioxidants are depleted, peroxidation of lipids occurs and might contribute to the toxicity of NO*2.
Research Interests: Biochemistry, Chemistry, Free Radicals, Medicine, Antioxidants, and 14 moreHumans, Nitric oxide, Antioxidant, Male, Bilirubin, Lipid peroxidation, High Pressure Liquid Chromatography, Uric Acid, Ascorbic Acid, Adult, Nitrogen Dioxide, Blood Proteins, Biochemistry and cell biology, and In Vitro Techniques
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Research Interests: Algorithms, Immune response, Biology, Medicine, Humans, and 15 moreSequence alignment, influenza A, Animals, Cytomegalovirus, Horses, Biochemical, Cattle, Ducks, Biological Process, influenza A virus, Amino Acid Sequence, Biochemistry and cell biology, Molecular Sequence Data, Sequence homology, and Medical biochemistry and metabolomics
Research Interests: Epidemiology, Environmental Health, Asthma, Allergy, Humans, and 15 moreCOPD, Diabetes mellitus, Female, Disease, Cohort, Aspirin, Clinical Sciences, Chronic obstructive pulmonary disease, Cardiovascular Diseases, Airway Obstruction, Atopy, ASTMA, Confidence Interval, Chronic Bronchitis, and hazard ratio
Copyright © 2011 Rokhsara Rafii et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is... more
Copyright © 2011 Rokhsara Rafii et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Chronic obstructive pulmonary disease (COPD) is a debilitating pulmonary disorder with systemic effects, and it is the fourth leading cause of death in the United States. COPD patients not only develop respiratory limitations, but can also demonstrate systemic wasting, features of depression, and can succumb to social isolation. Smoking cessation is crucial, and pharmacotherapy with bronchodilators is helpful in symptom management. Inhaled corticosteroids may be beneficial in some patients. In addition, pulmonary rehabilitation and palliative care are important components under the right clinical circumstance. This review highlights current guidelines and management strategies for COPD and emphasizes novel pharmacotherapy and minimal...
Difficult-to-control asthma in adults is under-diagnosed and under-treated in the United States, particularly in those 40 years of age or older. Increasing attention has been focused on the subset of adult patients with poorly controlled... more
Difficult-to-control asthma in adults is under-diagnosed and under-treated in the United States, particularly in those 40 years of age or older. Increasing attention has been focused on the subset of adult patients with poorly controlled asthma because they consume up to 85% of all health care dollars spent on asthma, while representing 20% of all asthma patients. In this article, we define difficult-to-control asthma and discuss the problem of misdiagnosis. We present an algorithm for confirming the diagnosis in these patients and highlight the importance of patient self-assessment. © 2007 Elsevier Inc. All rights reserved.
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The increasing use of advanced biologic therapies for patients with severe asthma is transforming the standard of care, clinic workflow, and the clinic business model. Expanded patient access to at-home injection treatment possibilities... more
The increasing use of advanced biologic therapies for patients with severe asthma is transforming the standard of care, clinic workflow, and the clinic business model. Expanded patient access to at-home injection treatment possibilities with some biologics has the potential to improve patient adherence and outcomes. Simultaneously, transition to the home setting can address the escalating costs that limit access for certain patients and healthcare facilities. Such moves come with recognized risks. Garnering input from physicians and other healthcare specialists as well as scrutinizing best practice position statements are vital to implementing truly patient-safe and cost-effective strategies in medicine. Mepolizumab is the first anti-IL-5 inhibitor to receive FDA approval in late 2015. We focus on this injectable medication and discuss the specific indications and contraindications for transitioning patients to at-home injection with mepolizumab. In doing so, we review our recent re...
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Research Interests: Medicine and Bronchoscopy
Asthma is a complex inflammatory disease with many triggers. The best understood asthma inflammatory pathways involve signals characterized by peripheral eosinophilia and elevated immunoglobulin E levels (called T2-high or allergic... more
Asthma is a complex inflammatory disease with many triggers. The best understood asthma inflammatory pathways involve signals characterized by peripheral eosinophilia and elevated immunoglobulin E levels (called T2-high or allergic asthma), though other asthma phenotypes exist (eg, T2-low or non-allergic asthma, eosinophilic or neutrophilic-predominant). Common triggers that lead to poor asthma control and exacerbations include respiratory viruses, aeroallergens, house dust, molds, and other organic and inorganic substances. Increasingly recognized non-allergen triggers include tobacco smoke, small particulate matter (eg, PM2.5), and volatile organic compounds. The interaction between respiratory viruses and non-allergen asthma triggers is not well understood, though it is likely a connection exists which may lead to asthma development and/or exacerbations. In this paper we describe common respiratory viruses and non-allergen triggers associated with asthma. In addition, we aim to s...
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Bronchial thermoplasty (BT) delivers targeted radiofrequency energy to bronchial airway walls and results in the partial ablation of the airway smooth muscle that is responsible for bronchoconstriction. It is approved for the treatment of... more
Bronchial thermoplasty (BT) delivers targeted radiofrequency energy to bronchial airway walls and results in the partial ablation of the airway smooth muscle that is responsible for bronchoconstriction. It is approved for the treatment of severe persistent asthma. Multiple, large clinical trials including a recent "real-world" study demonstrate significant improvements in asthma-related quality of life, reduction in asthma exacerbations, emergency department visits, and hospitalizations after BT that is sustained out to 5 years. In this article, we review the state of the art of BT treatment in severe persistent asthma and share a decade of BT research and clinical experience. We share our personal experience and introduce the three "I"s (identification, implementation, and intense follow-up) that we believe promote successful patient outcomes and help build a successful BT program.
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Research Interests: Immunology, Health Care, Asthma, Medicine, Bt, and 4 moreSevere Refractory Asthma, Dilemma, GuideLine, and Severe asthma
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Chronic obstructive pulmonary disease (COPD) is a complex and heterogeneous syndrome that represents a major global health burden. COPD phenotypes have recently emerged based on large cohort studies addressing the need to better... more
Chronic obstructive pulmonary disease (COPD) is a complex and heterogeneous syndrome that represents a major global health burden. COPD phenotypes have recently emerged based on large cohort studies addressing the need to better characterize the syndrome. Though comprehensive phenotyping is still at an early stage, factors such as ethnicity and radiographic, serum, and exhaled breath biomarkers have shown promise. COPD is also an immunological disease where innate and adaptive immune responses to the environment and tobacco smoke are altered. The frequent overlap between COPD and other systemic diseases, such as cardiovascular disease, has influenced COPD therapy, and treatments for both conditions may lead to improved patient outcomes. Here, we discuss current paradigms that center on improving the definition of COPD, understanding the immunological overlap between COPD and vascular inflammation, and the treatment of COPD-with a focus on comorbid cardiovascular disease.
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Gastroesophageal reflux disease is one of the most common comorbidities in patients with asthma. Gastroesophageal reflux disease can be linked to difficult-to-control asthma. Current management includes gastric acid suppression therapy... more
Gastroesophageal reflux disease is one of the most common comorbidities in patients with asthma. Gastroesophageal reflux disease can be linked to difficult-to-control asthma. Current management includes gastric acid suppression therapy and surgical antireflux procedures. The LINX® procedure is a novel surgical treatment for patients with gastroesophageal reflux disease refractory to medical therapy. To the best of our knowledge, we report the first case of successful treatment of refractory asthma secondary to gastroesophageal reflux disease using the LINX® procedure. Our patient was a 22-year-old white woman who met the American Thoracic Society criteria for refractory asthma that had remained poorly controlled for 5 years despite progressive escalation to step 6 treatment as recommended by National Institutes of Health-National Asthma Education and Prevention Program guidelines, including high-dose oral corticosteroids, high-dose inhaled corticosteroid plus long-acting β2-agonist,...
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Chronic obstructive pulmonary disease (COPD) is a debilitating pulmonary disorder with systemic effects, and it is the fourth leading cause of death in the United States. COPD patients not only develop respiratory limitations, but can... more
Chronic obstructive pulmonary disease (COPD) is a debilitating pulmonary disorder with systemic effects, and it is the fourth leading cause of death in the United States. COPD patients not only develop respiratory limitations, but can also demonstrate systemic wasting, features of depression, and can succumb to social isolation. Smoking cessation is crucial, and pharmacotherapy with bronchodilators is helpful in symptom management. Inhaled corticosteroids may be beneficial in some patients. In addition, pulmonary rehabilitation and palliative care are important components under the right clinical circumstance. This review highlights current guidelines and management strategies for COPD and emphasizes novel pharmacotherapy and minimally invasive (nonsurgical) lung-volume reduction interventions that may prove to be of significant benefit in the future.
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Research Interests: Palliative Care, Medicine, Humans, COPD, Smoking Cessation, and 13 morePulmonary Rehabilitation, Vaccination, Pharmacotherapy, Aged, Spirometry, Age Factors, Chronic obstructive pulmonary disease, Intensive Care Medicine, Oxygen therapy, Disease Management, Pharmacology and pharmaceutical sciences, Bronchodilator agents, and Pulmonary Disease Chronic Obstructive
The critical asthma syndrome (CAS) encompasses the most severe, persistent, refractory asthma patients for the clinician to manage. Personalized pharmacotherapy is necessary to prevent the next acute severe asthma exacerbation, not just... more
The critical asthma syndrome (CAS) encompasses the most severe, persistent, refractory asthma patients for the clinician to manage. Personalized pharmacotherapy is necessary to prevent the next acute severe asthma exacerbation, not just the control of symptoms. The 2007 National Asthma Education and Prevention Program Expert Panel 3 provides guidelines for the treatment of uncontrolled asthma. The patient's response to recommended pharmacotherapy is highly variable which risks poor asthma control leading to frequent exacerbations that can deteriorate into CAS. Controlling asthma symptoms and preventing acute exacerbations may be two separate clinical activities with their own unique demands. Clinicians must be prepared to use the entire spectrum of asthma medications available but must concurrently be aware of potential drug toxicities some of which can paradoxically worsen asthma control. Medications normally prescribed for COPD can potentially be useful in the CAS patient, particularly those with asthma-COPD overlap syndrome. Immunomodulation with drugs like omalizumab in IgE-mediated asthma syndromes is one important approach. New and emerging drugs address unique aspects of airway inflammation and biology but at a significant financial cost. The pharmacology and toxicities of the agents that may be used in the treatment of CAS to control asthma symptoms and prevent severe exacerbations are reviewed.
Research Interests: Immunology, Expert testimony, Asthma, Medicine, Humans, and 13 moreAnimals, Immunomodulation, Immunoglobulin E, Pharmacotherapy, Respiratory System, Drug Therapy, Chronic obstructive pulmonary disease, Intensive Care Medicine, Syndrome, Omalizumab, Critical Illness, Exacerbation, and Pulmonary Disease Chronic Obstructive
Idiopathic pulmonary fibrosis (IPF) is a disease of the elderly with a mean age at presentation of 66 years. It is the most common type of idiopathic lung fibrosis, and the most lethal, with a median survival of 3 to 5 years after... more
Idiopathic pulmonary fibrosis (IPF) is a disease of the elderly with a mean age at presentation of 66 years. It is the most common type of idiopathic lung fibrosis, and the most lethal, with a median survival of 3 to 5 years after diagnosis. Abnormalities in fibroblast and humoral response mechanisms may play a role in the pathogenesis of fibrosis in IPF. Clinical trials suggest that pirfenidone, an oral antifibrotic agent, N-acetylcysteine, an antioxidant and perhaps anticoagulation, may have some beneficial effect; however, large-scale studies are necessary for confirmation. Immunosuppression with corticosteroids likely does not confer benefit. Lung transplantation has been shown to improve survival in selected IPF patients. Comorbidities accompanying IPF include gastroesophageal reflux, sleep disturbance, pulmonary arterial hypertension, and coronary artery disease amongst others, and ought to be promptly recognized and managed appropriately. While the US Food and Drug Administration has not currently approved any treatments for IPF, patients with IPF should continue to be strongly encouraged to enroll in ongoing clinical trials for this devastating disease.
Research Interests: Immunology, Clinical Trial, Medicine, Comorbidity, Humans, and 15 morePulmonary fibrosis, Female, Aged, Lung fibrosis, Large Scale, Idiopathic Pulmonary Fibrosis, Coronary Artery Disease, Heart and Lung Transplantation, Food and Drug Administration, Gastroesophageal Reflux, Clinical Trials as Topic, Pirfenidone, Sleep Disturbance, Lung Transplantation, and Pulmonary artery hypertension
Research Interests: Immunology, Carbon Dioxide, Asthma, Critical Care, Humans, and 15 moreChild, African American, Emergency Room, Female, Length of Stay, General Anesthesia, Intensive Care Unit, Aged, Adult, Intensive Care Medicine, Bronchial Asthma, Intensive Care Units, Hospital Mortality, Child preschool, and Exacerbation
Research Interests: Immunology, Medicine, Humans, Basement Membrane, Female, and 15 moreHemodialysis, Immunotherapy, Middle Aged, Diagnostic Test, Glomerular Basement Membrane, Collagen Type IV, Early Diagnosis, Conformational Change, Autoantibodies, Glomerulonephritis, Hemoptysis, immunoglobulin G, Immunosuppressive Agents, Plasma exchange, and Kidney glomerulus
ABSTRACT Improving Quality and Reducing CostSESSION TYPE: Original Investigation SlidePRESENTED ON: Tuesday, October 29, 2013 at 02:45 PM - 04:15 PMPURPOSE: Hospital admissions and readmissions to the UC Davis Medical Center (UCDMC) for... more
ABSTRACT Improving Quality and Reducing CostSESSION TYPE: Original Investigation SlidePRESENTED ON: Tuesday, October 29, 2013 at 02:45 PM - 04:15 PMPURPOSE: Hospital admissions and readmissions to the UC Davis Medical Center (UCDMC) for Acute Exacerbation of Chronic Obstructive Pulmonary Disease (AECOPD) have increased since 2009 and represent an opportunity for multidisciplinary chronic disease management. In fiscal year (FY) 2011, average length of stay (LOS) for AECOPD was 7.57 days; readmission rate within 30 days after discharge was 16%. A COPD case management team was instituted March 2012 with the goal of intensifying patient education and streamlining patient access to primary and subspecialty services.METHODS: Seven RCP COPD Case Managers under the supervision of a pulmonologist, provided inpatient COPD education utilizing a written COPD Action Plan individualized for each patient that incorporated Global Initiative for Chronic Obstructive Lung Disease (GOLD) treatment guidelines. Four inpatient education sessions included anatomy and physiology of the respiratory system, proper inhalation device use, return demonstration, controlled breathing techniques, infection control, referral services, and medication reconciliation. At discharge, each patient was given continued access to the case manager on duty through a telephone pager.RESULTS: Between March 2012 and February 2013, 75 AECOPD patients were hospitalized: 41 (55%) were women, mean age was 69 years (range 46 to 88 years), 36% had very severe Grade IV COPD, 44% had severe Grade III COPD, 17% had moderate Grade II COPD, and 4% had mild Grade I COPD. Employing RCP COPD case management, average LOS for AECOPD was reduced by 1.9 days to 5.7 days for a projected cost savings of $6,511 per admission. Readmission rate was reduced from 16% in FY 2011 to 5% with projected cost savings of $481,814 during study period.CONCLUSIONS: RCP COPD Case Managers are effective in reducing hospital LOS and readmission for AECOPD.CLINICAL IMPLICATIONS: RCPs perform a vital role in a managed care model for integrating COPD care by improving patient education and facilitating healthcare navigation and utilization to achieve better outcomes and cost savings.DISCLOSURE: The following authors have nothing to disclose: Krystal Craddock, Michelle Young, Carrie Lipe, Anthony Yanes, Justin Griffiths, Rafael Antanesian, Patricia Brown, Brendy Avalos, Claudia Vukovich, John MacMillan, Nicholas Kenyon, Samuel LouieNo Product/Research Disclosure Information.
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Research Interests: Immunology, Diet, Autoimmunity, Medicine, Humans, and 15 moreCOPD, Pulmonary fibrosis, Smoking, Paradigm Shift, Incidence, Risk factors, Prevalence, Sex Factors, Chronic obstructive pulmonary disease, Risk Factors, Idiopathic Pulmonary Fibrosis, Tobacco Smoke, Chronic lung disease, Clinical Trials as Topic, and Pulmonary Disease Chronic Obstructive
• Asthma in adults is composed of a complex group of reversible airway disorders in contrast to childhood asthma that is largely allergic in nature. • Adult-onset asthma may be recently acquired in adulthood or represent various stages of... more
• Asthma in adults is composed of a complex group of reversible airway disorders in contrast to childhood asthma that is largely allergic in nature. • Adult-onset asthma may be recently acquired in adulthood or represent various stages of long-standing disease. Atopic adults may carry the genotype of childhood asthma symptomatically into adulthood only to have the phenotype finally expressed because of a powerful trigger, e.g., specific aeroallergen(s) or infection. • Approximately 31 million Americans suffer from asthma. The majority of patients (71%) are adults, whereas fewer than 29% (8.9 million) are children less than 18 yr of age. More women than men are affected with severe adult-onset asthma. Estrogen replacement therapy, respiratory infection with Chlamydia or Mycoplasma, certain occupations, tobacco smoking, gastroesophageal reflux, obesity, and sleep disorders are important risk factors and comorbid conditions. • Asthma and active cigarette smoking interact to cause more ...
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Tracheobronchial disruption is a rare, life-threatening injury associated with severe blunt chest trauma. Most injuries occur within 2.5 cm of the main carina and more often involve the right main bronchus. We report a case of occult... more
Tracheobronchial disruption is a rare, life-threatening injury associated with severe blunt chest trauma. Most injuries occur within 2.5 cm of the main carina and more often involve the right main bronchus. We report a case of occult tracheobronchial injury located in a left subsegmental bronchus discovered with flexible bronchoscopy in a 21-year-old man who sustained chest trauma after a motorcycle accident. He presented with a pneumomediastinum, right pneumothorax, and left hemothorax requiring thoracotomy to achieve hemostasis. Several hours postoperatively he developed refractory hypoxemia despite insertion of bilateral chest tubes and increased positive pressure ventilation. Flexible bronchoscopy at the bedside revealed the aforementioned bronchial disruption. A review of the literature on tracheobronchial injury and role of flexible bronchoscopy is presented.
Palliative care services for patients with chronic obstructive pulmonary disease (COPD) have been limited in most health care schemes despite the significant impact its symptoms can have on quality of life (QOL). Palliative care must be... more
Palliative care services for patients with chronic obstructive pulmonary disease (COPD) have been limited in most health care schemes despite the significant impact its symptoms can have on quality of life (QOL). Palliative care must be integrated to address physical and emotional distress and QOL deterioration more effectively. Multi-factorial barriers in current health care systems impede the provision of palliative care, including the lack of familiarity among health care professionals. There are sparse evidence-based studies and guidelines for clinicians to better recognize the need for palliative care in COPD patients compared to the large experience and resources available to cancer patients and hospice care. The multidisciplinary approach of palliative care should help COPD patients navigate through the continuum of chronic disease management. Highest QOL, not necessarily the highest physiologic goals, with relief of physical and emotional suffering, are most important to pat...
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,,Post-translational sulfation of tyrosines affects the affinity and binding of at least some chemokine,receptors to their ligand(s) and,has been hypothesized,to be a feature in all chemokine receptors. This binding initiatesdownstream... more
,,Post-translational sulfation of tyrosines affects the affinity and binding of at least some chemokine,receptors to their ligand(s) and,has been hypothesized,to be a feature in all chemokine receptors. This binding initiatesdownstream signaling cascades. By this mechanism, tyrosine sulfation can influence the cells involved in acute and chronic events of cellular immunity. These events include leukocyte trafficking and airway inflammation,important in
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ABSTRACT Difficult-to-control asthma in adult patients is a conundrum encountered frequently in clinical practice. Recognizing the range of asthma case presentations and conundrums can improve asthma treatment plans and better patient... more
ABSTRACT Difficult-to-control asthma in adult patients is a conundrum encountered frequently in clinical practice. Recognizing the range of asthma case presentations and conundrums can improve asthma treatment plans and better patient outcomes. KeywordsAsthma–Asthma comorbidity–Refractory asthma