A 28-Year-Old Pregnant Woman With a Lung Abscess and Complicated Pleural Effusion.

CASE PRESENTATION: A 28-year-old woman G1P0 at 22 weeks of gestation and with no significant medical history presented to the ED complaining of worsening dyspnea and right-sided pleuritic chest pain. Symptoms started 2 weeks before presentation, with minimal productive cough and dyspnea on exertion. One week after the initial symptoms, the patient started noticing right-sided chest and shoulder pain along with subjective fevers and night sweats. She denied hemoptysis, weight loss, abdominal pain, diarrhea, nausea, vomiting, arthralgia, or rash. Her pregnancy had so far been uncomplicated. The patient did not use tobacco, alcohol, or recreational drugs. She worked at a daycare center but denied any particular sick contacts. She moved to the United States 7 years ago from Sudan and denied any recent travel.

Sarcoidosis.

Sarcoidosis is a multisystemic granulomatous disease that affects individuals worldwide. The lungs are most commonly involved but any organ can be involved. It has variable manifestations and clinical course. Diagnosis of sarcoidosis is based on clinicopathologic findings and the exclusion of other causes of granulomatous disease. Its hallmark is the formation of granulomas in affected organs. Immunosuppressive therapy is the cornerstone of the management of sarcoidosis and is indicated when there is evidence of symptomatic or progressive disease or when critical organs (ocular, cardiac, nervous system) are involved.

Pharyngeal collapsibility during sleep is elevated in insulin-resistant females with morbid obesity.

Insulin resistance is associated with sleep apnoea, leading us to hypothesise that it is also associated with elevations in pharyngeal collapsibility, even in the absence of sleep apnoea.90 bariatric patients were characterised for sleep apnoea, pharyngeal collapsibility and insulin resistance. Patients with a respiratory disturbance index (RDI) >10 events·h(-1), diabetes mellitus, tonsillar hypertrophy and pulmonary disease were excluded. The remaining 14 females underwent collapsibility measurements (passive critical pressure, Pcritp ) during non-rapid eye movement sleep. The homeostasis model assessment (HOMA) index, a measure of insulin resistance, was derived from measurements of fasting glucose and insulin levels, and compared to Pcritp Groups with high Pcritp compared to low Pcritp did not differ in age, body mass index or RDI. HOMA and insulin were elevated in the high Pcritp group compared to the low Pcritp group (p<0.02). Pcritp correlated with HOMA (Spearman's ρ=0.565, 95% CI 0.104-0.862; p=0.035) and insulin (Spearman's ρ=0.609 95% CI 0.196-0.835; p=0.021).Obese insulin-resistant subjects without frank diabetes or sleep apnoea demonstrate preclinical elevations in pharyngeal collapsibility, which may increase their susceptibility to sleep apnoea. Our findings suggest that insulin resistance could play a significant role in sleep apnoea pathogenesis by generating requisite elevations in pharyngeal collapsibility.

Incidence of Atrial Fibrillation After Atrial Flutter Ablation.

OBJECTIVES: This study was conceived to perform a comprehensive systematic review and meta-analysis of the available evidence to compute the incidence of atrial fibrillation (AF) after successful atrial flutter (AFL) catheter ablation, defined by targeting for bidirectional block, using different types of follow-up modalities and durations. BACKGROUND: Cavotricuspid-isthmus dependent AFL is usually initiated by short bursts of AF. The incidence of AF after AFL ablation is variable. We evaluated the variation in the reported incidence of AF depending on the type and duration of follow-up, and AF incidence in patients with prior AF versus no prior AF. METHODS: A systematic review and meta-analysis of published studies between January 1996 and April 2015 and abstracts in the last 2 years describing patients who underwent AFL ablation and the subsequent incidence of AF was performed. RESULTS: Forty-eight studies were included (n = 8,257, ablation success rate: 96%, 79% male). Incidence of new-onset AF correlated with follow-up duration (29% for a weighted mean follow-up duration of 30 months). New-onset AF incidence with <2 years follow-up was 12.4% among group 1 (electrocardiogram and symptoms-driven evaluation, n = 759), 19% for group 2 (outpatient Holter monitoring for 1 day to 7 days/year, n = 315), and 45% for group 3 (>7 days/year Holter monitoring or by implanted cardiac devices, n = 178). Mean follow-up duration was 15.3 months, 18.5 months, and 16.3 months, respectively. In patients with and without prior AF, the incidence for AF after AFL ablation was 35.3% during mean follow-up duration of 29.7 months. In studies with <2 years follow-up duration, AF incidence was 54% in patients with prior AF versus 13.9% without prior AF (odds ratio: 7.43, 95% confidence interval: 4.96 to 11.11; p < 0.00001). In studies with >2 years follow-up duration, AF incidence was 51.3% in patients with prior AF versus 26.2% without prior AF (odds ratio: 2.93, 95% confidence interval: 2.42 to 3.56; p < 0.00001). CONCLUSIONS: The incidence of AF after AFL ablation is high especially in patients with prior AF when compared to those without prior AF. The detection of AF in patients without prior AF significantly increases with more frequent monitoring and/or longer follow-up duration.

Caregiver perception of sleep-disordered breathing-associated symptoms in children of rural Andean communities above 4000 masl with chronic exposure to biomass fuel.

BACKGROUND: Previous studies have uncovered a very high prevalence of sleep disorders in general, and of sleep-disordered breathing in particular among children exposed to indoor biomass fuel pollution. However, despite the significant symptomatology, parents are unlikely to report these issues during health-care visits. OBJECTIVE: The objective of this study was to determine whether reduced caregiver perception of sleep disorders may account for the infrequent diagnosis and treatment of such problems in children residing at high altitudes and exposed to high biomass pollution. METHODS: Parents of children aged 9-15 years of three communities residing in the Pasco region in Peru located between 3800 and 4200 meters above sea level were surveyed using a validated questionnaire instrument focused on symptoms associated with sleep-disordered breathing as well as whether caregivers perceived that their child suffered from a sleep disorder. RESULTS: Among the 77 children included, 48.1% had nocturnal awakenings and 46.8% had repetitive movements and restless sleep. Habitual snoring was present in 33.8% of all children. However, only 10.4% of mothers considered that their children had sleep problems, and all of their children had positive answers for ≥4 sleep symptoms. CONCLUSIONS: Children residing at high altitudes and exposed to traditional biomass-fueled stoves exhibit an extremely high frequency of sleep symptoms that are misperceived by their mothers as being "normal." Interventions aimed at increasing parental recognition and awareness of sleep problems will be essential to foster improved diagnosis and treatment.

Adherence to reduced-polluting biomass fuel stoves improves respiratory and sleep symptoms in children.

BACKGROUND: Symptoms of sleep apnea are markedly increased in children exposed to smoke from biomass fuels and are reduced by kitchen stoves that improve indoor biomass pollution. However, the impact of adherence to the use of improved stoves has not been critically examined. METHODS: Sleep-related symptom questionnaires were obtained from children <15 years of age in 56 families residing in the communities of Lliupapuquio, Andahuaylas province in Peru before and 2 years after installation of less-polluting Inkawasi cooking stoves. RESULTS: 82 children with lifetime exposures to indoor fuel pollution were included. When compared to those alternating between both types of stoves or those using traditional stoves only, those children who exclusively used Inkawasi cooking stoves showed significant improvements in sleep and respiratory related symptoms, but some minor albeit significant improvements occurred when both stoves were concomitantly used. CONCLUSIONS: Improvements in respiratory and sleep-related symptoms associated with elevated indoor biomass pollution occur only following implementation and exclusive utilization of improved kitchen stoves.