Characteristics of patients with mild to moderate primary pulmonary coccidioidomycosis.

In Arizona, USA, primary pulmonary coccidioidomycosis accounts for 15%-29% of community-acquired pneumonia. To determine the evolution of symptoms and changes in laboratory values for patients with mild to moderate coccidioidomycosis during 2010-2012, we conducted a prospective 24-week study of patients with primary pulmonary coccidioidomycosis. Of the 36 patients, 16 (44%) were men and 33 (92%) were White. Median age was 53 years, and 20 (56%) had received antifungal treatment at baseline. Symptom scores were higher for patients who received treatment than for those who did not. Median times from symptom onset to 50% reduction and to complete resolution for patients in treatment and nontreatment groups were 9.9 and 9.1 weeks, and 18.7 and 17.8 weeks, respectively. Median times to full return to work were 8.4 and 5.7 weeks, respectively. One patient who received treatment experienced disseminated infection. For otherwise healthy adults with acute coccidioidomycosis, convalescence was prolonged, regardless of whether they received antifungal treatment.

Evidence for liver injury in the setting of obstructive sleep apnea.

INTRODUCTION: Obstructive sleep apnea (OSA) and non-alcoholic fatty liver disease (NAFLD) are both strongly associated with obesity. Whether OSA is an independent risk factor for liver injury is uncertain. OBJECTIVE: To assess the hypothesis that OSA is associated with liver injury independent of obesity. MATERIALS AND METHODS: We reviewed the histories of 73 consecutive patients referred to a hospital-based sleep lab because of suspected OSA. OSA was determined to be present if the apnea-hypopnea index was > 10. Obesity was defined as a BMI ≥ 30 kg/m 2 . Patients were included for analysis if they had aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels obtained within 60 days of sleep study. Patients with evidence of viral hepatitis, autoimmune-, metabolic- or established alcoholic-liver disease were excluded. Patients who reported alcohol intake equivalent to a dose ≥ 20 g/day were also excluded. 53 of 73 patients met study criteria. Patients were subdivided for analysis into groups meeting or not meeting OSA and obesity criteria, and having or not having elevated aminotransferase levels. RESULTS: 35/53 patients (66%) had OSA. 31/53 (58%) patients were obese. 15 (28%) and 12 (23%) patients had elevated AST and ALT, respectively. Mean age, gender distribution, mean BMI and percentage with either diabetes or hyperlipidemia were not significantly different in those with or without OSA. Elevated ALT was found in 11/35 (31%) patients with OSA, compared to 1/18 patients without OSA (p = 0.041). Frequency of elevated AST [obese 11/31 (35%); non-obese 4/22 (18%)] or ALT [obese 10/31 (32%); non-obese 2/22 (9%)] was not significantly different in the obese and non-obese cohorts. CONCLUSIONS: OSA may be a risk factor for liver injury independent of obesity. The prevalence and nature of liver disease in the setting of OSA should be determined with larger, prospective studies. The impact of OSA treatment, if any, on liver injury should be similarly evaluated.

The utility of Coccidioides polymerase chain reaction testing in the clinical setting.

Coccidioidomycosis, the fungal infection caused by dimorphic Coccidioides sp., is typically diagnosed by histopathologic identification of spherules in affected secretions and tissues or by culture. These tests are reliable but time-intensive, delaying diagnosis and treatment. To evaluate a polymerase chain reaction (PCR) test developed to detect Coccidioides sp. in clinical specimens, we conducted a retrospective chart review of all patients (N = 145) who underwent Coccidioides PCR at our institution between April 27, 2007, and May 6, 2008, abstracting clinical, microbiologic, serologic, radiographic, treatment, and follow-up data. One hundred fifty-eight PCR tests (153 respiratory; 5 cerebrospinal fluid) produced 5 positive and 153 negative findings. Five of nine patients (56%) with confirmed or highly probable pulmonary coccidioidomycosis had a positive PCR on respiratory specimens, and four of nine (44%) had a positive culture. Among two patients with coccidioidal meningitis, none had a positive PCR, whereas Coccidioides sp. in fungal culture grew for one of two. Among six asymptomatic patients with probable coccidioidomycosis, none had a positive culture or PCR. Compared with culture of respiratory specimens, PCR demonstrated a sensitivity, specificity, positive predictive value, and negative predictive value of 75, 99, 60, and 99%, respectively. Coccidioides PCR appears accurate in identifying negative results, and its sensitivity is similar to that of fungal culture.

Subpectoral implantation of the hypoglossal nerve stimulator: An effective technical modification.

Upper airway stimulation is now a well-established treatment option for selected patients with obstructive sleep apnea. The implanted pulse generator of this system activates the hypoglossal nerve and is routinely placed in a subcutaneous pocket overlying the pectoralis muscle. This case report describes a patient with a history of bilateral mastectomy and radiation for breast cancer who required explantation due to device exposure and infection. The patient was successfully reimplanted by placing the implantable pulse generator deep to the pectoralis major muscle. Clinical circumstances involving the chest wall may warrant subpectoral placement of the implanted pulse generator. Laryngoscope, 129:2420-2423, 2019.

Individuals With Scleroderma May Have Increased Risk of Sleep-Disordered Breathing.

STUDY OBJECTIVES: Scleroderma is associated with abnormal skin thickening, interstitial lung disease, pulmonary hypertension, and abnormalities of the upper airway. These changes can cause cardiopulmonary complications, potentially including sleep-disordered breathing. The objective of this study is to examine the risk of sleep-disordered breathing in patients with scleroderma. METHODS: We retrospectively identified patients with documented scleroderma. We abstracted data from their electronic health records, including findings from antibody tests, serial pulmonary function tests, transthoracic echocardiography, high-resolution computed tomography, and overnight forehead oximetry. RESULTS: We identified 171 patients with scleroderma. Mean age at the time of initial consult was 56.5 years (range, 18-96 years), and 150 (86.7%) were women. Scleroderma was categorized as limited disease for 108 (62.4%), diffuse disease for 59 (34.1%), and mixed connective tissue disease for 6 (3.5%). Fifty-four patients (31.2%) had abnormal overnight forehead oximetry results, defined as an oxygen desaturation index greater than 5 or a baseline mean arterial oxygen saturation level less than 90%. CONCLUSIONS: Cardiopulmonary complications are common in patients with scleroderma, one of which may be sleep-disordered breathing. In our cohort, approximately one-third of individuals with scleroderma had evidence of sleep-disordered breathing. Moreover, the rate of sleep-disordered breathing in our population of scleroderma patients was twice the rate of pulmonary hypertension and was approximately the same as the rate of interstitial lung disease. Future prospective studies are needed to further assess the role of sleep-disordered breathing in scleroderma clinical outcomes.

Coccidioidomycosis.

Coccidioidomycosis is a common infectious disease in the southwestern United States. Although Coccidioides species are not endemic in other areas of the country, the rapid population growth in the southwestern United States in recent decades and the increase in tourism mean that many people travel to the Southwest and return home before developing the clinical syndrome of coccidioidomycosis. In this respect, coccidioidomycosis is a disease of national importance. It can occur in various manifestations: acute pneumonia, chronic progressive pneumonia, pulmonary nodules and cavities, extrapulmonary nonmeningeal disease, and meningitis. The diagnosis is often made on the basis of serologic findings. Treatment is usually with an azole or amphotericin B, depending on the clinical manifestations and the immune status of the host. We discuss the most common clinical manifestations, the best way to make the diagnosis, and the treatment of common infections.

Obstructive sleep apnea: A better Dx model for primary care.

This study identified a method that provides a truer assessment of disease probability than has been achieved with history and physical exam evaluation.

"Idiopathic" rapid-eye-movement (REM) sleep behavior disorder is associated with future development of neurodegenerative diseases.

OBJECTIVE: To determine whether a diagnosis of idiopathic rapid-eye-movement sleep behavior disorder (RBD) is associated with a future risk of development of neurodegenerative diseases. METHODS: We addressed the objective through development of a structured critically appraised topic that included a clinical scenario, structured question, search strategy, critical appraisal, results, summary of best evidence, commentary, and bottom-line conclusions. Participants included consultant and resident neurologists, clinical epidemiologists, medical librarians, and clinical content experts. RESULTS: A retrospective study of 44 consecutive patients diagnosed with idiopathic RBD demonstrated that 20 patients (45%) developed a neurologic disorder, most commonly Parkinson disease or Lewy body dementia, after a mean of 11.5 years from reported symptom onset and 5.1 years after RBD diagnosis. CONCLUSION: Currently available evidence is limited to cross-sectional and retrospective analyses of patients with RBD. Although ascertainment biases and the retrospective nature of the available evidence limits quantitative analyses, the diagnosis of idiopathic RBD portends a risk of greater than 45% for future development of a clinically defined neurodegenerative disease. This finding has significant implications for clinical neurologic and sleep disorder practice and neurodegenerative disease research.

The Effect of Dogs on Human Sleep in the Home Sleep Environment.

OBJECTIVE: To objectively assess whether a dog in the bedroom or bed disturbs sleep. PARTICIPANTS AND METHODS: From August 1, 2015, through December 31, 2015, we evaluated the sleep of humans and dogs occupying the same bedroom to determine whether this arrangement was conducive to sleep. The study included 40 healthy adults without sleep disorders and their dogs (no dogs <6 months old). Each participant wore an accelerometer and their dog a validated dog accelerometer for 7 nights. RESULTS: The mean ± SD age of the participants (88% women) was 44±14 years and body mass index was 25±6. The mean ± SD age of the dogs was 5±3 years and weight was 15±13 kg. Mean ± SD actigraphy data showed 475±101 minutes in bed, 404±99 minutes total sleep time, 81%±7% sleep efficiency, and 71±35 minutes wake time after sleep onset. The dogs' accelerometer activity during the corresponding human sleep period was characterized as mean ± SD minutes at rest, active, and at play of 413±102, 62±43, and 2±4. The dogs had mean ± SD 85%±15% sleep efficiency. Human sleep efficiency was lower if the dog was on the bed as opposed to simply in the room (P=.003). CONCLUSION: Humans with a single dog in their bedroom maintained good sleep efficiency; however, the dog's position on/off the bed made a difference. A dog's presence in the bedroom may not be disruptive to human sleep, as was previously suspected.

A preliminary fluorodeoxyglucose positron emission tomography study in healthy adults reporting dream-enactment behavior.

STUDY OBJECTIVES: To test the hypothesis that healthy adults reporting dream-enactment behavior (DEB+) have reduced cerebral metabolic rate for glucose (CMRgl) in regions preferentially affected in patients with dementia with Lewy bodies (DLB). DESIGN: Automated brain-mapping algorithms were used to compare regional fluorodeoxyglucose (FDG) positron emission tomography (PET) measurements from previously evaluated DEB cases and controls. SETTING: Tertiary-care academic medical centers. PARTICIPANTS: Seventeen cognitively normal patients with DEB+ and 17 control subjects (DEB-) who were individually matched for age (59 +/- 11 years), education level (16 +/- 4 years), sex (67% women), body mass index (26 +/- 4.8 kg/m2), first-degree relative with dementia (85%), and proportion of apolipoprotein E (APOE) e4 carriers (13 e4 carriers, 4 noncarriers). INTERVENTIONS: FDG-PET. MEASUREMENTS AND RESULTS: DEB was associated with significantly lower CMRgl in several brain regions known to be preferentially affected in both DLB and Alzheimer disease (parietal, temporal, and posterior cingulate cortexes) and in several other regions, including the anterior cingulate cortex (p < .001, uncorrected for multiple comparisons). The DEB-associated CMRgl reductions were significantly greater in the APOE e4 noncarriers than in the carriers. CONCLUSIONS: These preliminary findings suggest that cognitively normal persons with DEB have reduced CMRgl in brain regions known to be metabolically affected by DLB, supporting further study of DEB as a possible risk factor for the development of DLB.

Suvorexant: a promising, novel treatment for insomnia.

Suvorexant a novel, orexin receptor antagonist was recently approved by the US Food and Drug Administration for the treatment of sleep onset and sleep maintenance insomnia in August 2014. Multiple animal and human studies support the efficacy, safety, and tolerability of suvorexant for patients of various profiles. Current recommendations advocate for a starting dose of 10 mg and a maximum dose of 20 mg, with cautious use in women, obese patients, and patients taking other CYP3A4 inhibitors. More head-to-head studies comparing suvorexant to other sedative-hypnotic therapies are needed to further delineate which patients will benefit the most from this medication over others.

Pulmonary Epithelioid Hemangioendothelioma Diagnosed With Endobronchial Biopsies: A Case Report and Literature Review.

Pulmonary epithelioid hemangioendothelioma (PEHE) is a rare vascular tumor of endothelial origin first described in 1975 as intravascular bronchioloalveolar tumor. Since then, >100 cases have been reported, and most cases require surgical lung biopsy for diagnosis. We report the case of a 46-year-old man with a diagnosis of PEHE from endobronchial biopsies of an intraluminal nodule, a rare presentation of this disease. We summarize a review of the literature and the bronchoscopic findings of PEHE.

Evolution in reimbursement for sleep studies and sleep centers.

Because of the rapid increase in the volume and costs of polysomnography and other sleep medicine diagnostic services, the Centers for Medicare & Medicaid Services (CMS) recently commissioned the Office of Inspector General (OIG) to review claims submitted for these services. The OIG found numerous cases of inappropriate payment for submitted claims and recommended significant changes in the CMS auditing process for polysomnography claims review. Additionally, a local Medicare Administrative Contractor released the most specific rules and regulations to date regarding billing and payment for sleep medicine services. These regulations specify covered diagnoses for submitted claims for both facility-based polysomnograms and unattended home sleep tests (HSTs) and list noncovered diagnoses that cannot be used to document medical necessity for such studies. The proposed rules specify minimum credentials for technologists performing polysomnograms and HSTs, mandate education prior to application of HST devices, demand a follow-up visit to discuss results after studies, and elaborate new requirements for physicians interpreting these studies. Providers of sleep medicine services must be prepared to provide documentation of diagnoses and indications when submitting claims for sleep services, and they can expect to be required to produce evidence of accreditation of the physicians and technologists providing services and the credentials of the sleep center. These changes will dramatically affect sleep medicine practitioners who order sleep studies and positive airway pressure therapies. Successful sleep medicine centers and sleep physicians alike will need to develop strategies to meet these new challenges.

The use of auto-titrating continuous positive airway pressure for treatment of adult obstructive sleep apnea. An American Academy of Sleep Medicine review.

This paper reviews the efficacy of auto-titrating continuous positive airway pressure (APAP) for treatment of obstructive sleep apnea. It is based on a review of 30 articles published in peer review journals conducted by a task force appointed by the American Academy of Sleep Medicine to develop practice parameters for use of APAP devices for treatment of obstructive sleep apnea (OSA). The data indicate that APAP can be used to treat many patients with OSA (auto-adjusting) or to identify an effective optimal fixed level of continuous positive airway pressure (CPAP) for treatment (auto-titration). Patients with significant congestive heart failure, chronic obstructive pulmonary disease (COPD), or significant amounts of central apnea were excluded from many treatment trials and there is insufficient evidence that APAP can be used to treat these patients. Many clinical trials have been performed in patients already on CPAP or with the initial APAP night in a laboratory setting. At this time only a few studies have evaluated initial titration with APAP in CPAP-naïve patients in an unattended setting. Further studies of APAP in this circumstance are needed. No studies have systematically compared the efficacy of one APAP technology with another. Devices using different technology may not give the same results in a given patient. Devices solely dependent on vibration may not work in non-snorers or patient who have undergone upper-airway surgery. High mask or mouth leaks may prevent adequate titration in devices monitoring snoring, flow, or impedance (forced oscillation technique). Review of the raw data to identify periods of high leak was performed in several of the APAP titration studies, to identify a pressure for fixed CPAP treatment or to determine if the titration was adequate. There is conflicting evidence for and against the premise that treatment with APAP increases acceptance and adherence compared to fixed CPAP. In studies demonstrating an increase in adherence with APAP, there was similar improvement in measures of daytime sleepiness as with fixed CPAP treatment. Further studies are needed to determine if APAP can increase acceptance or adherence with positive pressure treatment in patients with OSA.

Obstructive sleep apnea and cardiovascular disease.

Obstructive sleep apnea (OSA) is a common medical condition that occurs in approximately 5% to 15% of the population. The pathophysiology of OSA is characterized by repetitive occlusions of the posterior pharynx during sleep that obstruct the airway, followed by oxyhemoglobin desaturation, persistent inspiratory efforts against the occluded airway, and termination by arousal from sleep. Obstructive sleep apnea is associated with daytime sleepiness and fatigue, likely due to fragmented sleep from recurrent arousals. Substantial evidence shows that patients with OSA have an increased incidence of hypertension compared with individuals without OSA and that OSA is a risk factor for the development of hypertension. Recent studies show that OSA may be implicated in stroke and transient ischemic attacks. Obstructive sleep apnea appears to be associated with coronary heart disease, heart failure, and cardiac arrhythmias. Pulmonary hypertension may be associated with OSA, especially in patients with preexisting pulmonary disease. Although the exact cause that links OSA with cardiovascular disease is unknown, there is evidence that OSA is associated with a group of proinflammatory and prothrombotic factors that have been identified to be important in the development of atherosclerosis. Obstructive sleep apnea is associated with increased daytime and nocturnal sympathetic activity. Autonomic abnormalities seen in patients with OSA include increased resting heart rate, decreased R-R interval variability, and increased blood pressure variability. Both atherosclerosis and OSA are associated with endothelial dysfunction, increased C-reactive protein, interleukin 6, fibrinogen, and plasminogen activator inhibitor, and reduced fibrinolytic activity. Obstructive sleep apnea has been associated with enhanced platelet activity and aggregation. Leukocyte adhesion and accumulation on endothelial cells are common in both OSA and atherosclerosis. Clinicians should be aware that OSA may be a risk factor for the development of cardiovascular disease.

Upper lobe pulmonary fibrosis associated with high-dose chemotherapy containing BCNU for bone marrow transplantation.

Upper lobe fibrotic lung disease is most often associated with sarcoidosis, Langerhans cell histiocytosis, silicosis, and other pneumoconioses but is usually not associated with drug-induced lung disease. Carmustine (BCNU) is a chemotherapeutic agent known to cause pulmonary toxicity. The radiographic pattern is usually diffuse bilateral lung disease predominantly in the lung bases. Upper lobe fibrotic disease associated with BCNU has been reported to occur in children treated for central nervous system gliomas. Often the lung disease occurs years after the exposure. Despite the widespread use of BCNU in the treatment of malignancy in adults, to our knowledge, the complication of upper lobe fibrotic disease has not been reported in adults. We describe a patient who presented with pneumothorax and bilateral upper lobe pulmonary fibrosis that we believe was due to BCNU given for bone marrow transplantation as part of therapy for breast cancer. Bilateral upper lobe pulmonary fibrosis can be associated with chemotherapeutic drugs.

Quality of life in bed partners of patients with obstructive sleep apnea or hypopnea after treatment with continuous positive airway pressure.

OBJECTIVE: Obstructive sleep apnea (OSA) has been shown to affect the quality of life (QOL) in patients, and QOL improves after treatment with nasal continuous positive airway pressure (CPAP). However, the effects on the bed partner of the patient with OSA have received little attention. We studied QOL in patients with OSA and their bed partners, and the effect of CPAP therapy on QOL. DESIGN: Fifty-four patients and their bed partners who had been seen for evaluation of OSA, had undergone polysomnography, and subsequently had received treatment with CPAP. Patients and bed partners completed the Epworth sleepiness scale (ESS) and QOL questionnaires before and after the patients' therapy. SETTING: Sleep disorders center in an academic medical center. PARTICIPANTS: Patients with documented OSA and regular bed partners. INTERVENTIONS: Both individuals completed the 36-item short-form health survey (SF-36), the ESS, and the Calgary sleep apnea quality of life index (SAQLI). At about 6 weeks after CPAP therapy, patients and their bed partners completed the same set of questionnaires again. RESULTS: Of the 54 subjects who completed the study, the mean (+/- SD) apnea-hypopnea index was 48.4 +/- 33.3. For the subjects, the mean ESS decreased from 12.9 +/- 4.4 to 7.3 +/- 4.0 (p < 0.001) after treatment with CPAP. For the bed partners, the mean ESS decreased from 7.4 +/- 6.1 to 5.8 +/- 4.7 (p = 0.02). The mean scores on the SAQLI were 4.1 +/- 1.0 for the subjects and 4.5 +/- 1.3 for the bed partners. Following CPAP therapy, the SAQLI increased in the subjects to 4.9 +/- 1.2 (p < 0.001), and in the bed partners to 5.1 +/- 0.9 (p = 0.002). The SF-36 showed positive changes in both the subjects and the bed partners. Significant improvements were observed in the subjects in role-physical, vitality, social functioning, role-emotional, and mental health domains. In the bed partners, significant changes in the SF-36 were observed in role-physical, vitality, social functioning, and mental health domains. CONCLUSION: OSA results in impaired QOL in both the patients and their bed partners. Treatment with CPAP improves QOL, as measured by the SF-36 and the SAQLI.

Pseudomembranous tracheobronchitis caused by Rhizopus sp. After allogeneic stem cell transplantation.

Invasive fungal infections are a major cause of morbidity and mortality in allogeneic stem cell transplant recipients. They can occasionally involve the tracheobronchial tree with serious clinical consequences. Tracheobronchial involvement is often an unexpected finding during diagnostic bronchoscopy. Herein, we report a case of pseudomembranous tracheobronchitis caused by Rhizopus sp. in an allogeneic stem cell transplant recipient.