The Evolution of Pulmonary Hypertension and Its Prognostic Implications Post-TAVI-Single Center Experience.

Background and Objectives: Since the first transcatheter aortic valve implantation (TAVI) procedure was performed in 2002, advances in technology and refinement of the method have led to its widespread use in patients with severe aortic stenosis (AS) and high surgical risk. We aim to identify the impact of TAVI on the clinical and functional status of patients with severe AS at the one-month follow-up and to identify potential predictors associated with the evolution of pulmonary hypertension (PH) in this category of patients. Materials and Methods: We conducted a prospective study which included 86 patients diagnosed with severe AS undergoing TAVI treatment. We analyzed demographics, clinical and echocardiographic parameters associated with AS and PH both at enrolment and at the 30-day follow-up. Results: In our study, the decrease of EUROSCORE II score (p < 0.001), improvement of angina (p < 0.001) and fatigue (p < 0.001) as clinical benefits as well as a reduction in NYHA functional class in patients with heart failure (p < 0.001) are prognostic predictors with statistical value. Regression of left ventricular hypertrophy (p = 0.001), increase in the left ventricle ejection fraction (p = 0.007) and improvement of diastolic dysfunction (p < 0.001) are echocardiographic parameters with a prognostic role in patients with severe AS undergoing TAVI. The pulmonary artery acceleration time (PAAT) (p < 0.001), tricuspid annular plane systolic excursion (TAPSE) (p = 0.020), pulmonary arterial systolic pressure (PASP) (p < 0.001) and the TAPSE/PASP ratio (p < 0.001) are statistically significant echocardiographic parameters in our study that assess both PH and its associated prognosis in patients undergoing TAVI. Conclusions: PAAT, TAPSE, PASP and the TAPSE/PASP ratio are independent predictors that allow the assessment of PH and its prognostic implications post-TAVI.

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.

A Case of Unilateral Hyperlucency of the Lung: a Rare Adult Occurrence of Swyer-James-MacLeod Syndrome.

Swyer-James-MacLeod syndrome is a rare pulmonary disorder that exhibits unilateral hyperlucency of a part of or the entire lung and because it is usually asimptomatic the diagnostic of this illness is discovered accidentally after a chest X-ray. Although the cause of this disorder is not completely understood, most authors believe that this is due to late sequela of infectious bronchiolitis that occurs during childhood. The symptoms presented by the individuals are often scarce at the moment of diagnostic, but a history of recurrent episodes of pulmonary infection accompanied by dyspnea, hemoptysis and/or chronic productive cough should raise the suspicion for such a diagnosis. Swyer-James-MacLeod syndrome can be interpreted as asthma or pulmonary embolism and this can result in inappropriate therapy. This case report describes a 38-year-old patient with chronic respiratory symptoms diagnosed on the findings of the chest X-ray and high resolution CT.

Imbalance in the diurnal salivary testosterone/cortisol ratio in men with severe obstructive sleep apnea: an observational study / Desequilíbrio na proporção salivar diurna de testosterona/cortisol em homens com apneia obstrutiva do sono grave: um estudo observacional

ABSTRACT INTRODUCTION: The complex relationship between sleep disorders and hormones could lead to alterations in the production of cortisol and testosterone in obstructive sleep apnea (OSA) patients. OBJECTIVE: The purpose of this study was to determine the diurnal trajectories of salivary free-testosterone, free-cortisol and their ratio (T/C). METHODS: Ten subjects newly diagnosed with OSA, based on nocturnal polysomnography evaluation and excessive daytime sleepiness, and seven matched controls were consecutively recruited. Cortisol and testosterone were measured in salivary samples collected upon awakening, at noon and in the evening. The psychometric evaluation of anxiety/depression and referred sexual function disturbances was performed to evaluate the presence of neuropsychological comorbidities. RESULTS AND CONCLUSION: The main finding was that OSA subjects displayed hypocortisolism upon awakening and a significant reduction in testosterone concentration in the evening in comparison with the control group, which has maintained the physiological testosterone and cortisol diurnal fluctuation, with higher hormone concentrations in the morning and lower concentrations in the evening. The use of data from multiple diurnal measurements rather than a single point allowed the detection of T/C ratio changes of opposite signs at the beginning and end of the day: the OSA subjects had a higher T/C ratio than the controls in the morning, while their T/C ratio was significantly lower than that of the controls in the evening. The imbalances in the anabolic-catabolic diurnal equilibrium suggest that OSA is associated with a dysregulation of the hypothalamic-pituitary-adrenal and hypothalamic-pituitary-gonadal axes, potentially an underlying cause of some of the neuropsychological comorbidities observed in OSA patients.

Resumo Introdução: A relação complexa entre os distúrbios do sono e os hormônios pode levar a alterações na produção de cortisol e testosterona em pacientes com Apneia obstrutiva do sono (AOS). Objetivo: O objetivo deste estudo foi determinar as curvas diurnas de testosterona e cortisol livres na saliva e sua proporção (razão T/C). Método: Dez indivíduos recém-diagnosticados com AOS com base na avaliação por polissonografia noturna e sonolência diurna excessiva e sete controles pareados foram recrutados, consecutivamente. Cortisol e testosterona foram medidos em amostras de saliva coletadas ao acordar, ao meio-dia e à noite. A avaliação psicométrica dos distúrbios de ansiedade/depressão e função sexual mencionados foi realizada para detectar a presença de comorbidades neuropsicológicas. Resultados: O achado principal foi que os indivíduos com AOS apresentam hipocortisolismo ao acordar e uma redução significante na concentração de testosterona à noite, em comparação com o grupo controle, que manteve a variação fisiológica diurna de testosterona e cortisol com concentrações hormonais mais elevadas pela manhã e concentrações mais baixas durante a noite. O uso de dados de várias mensurações diurnas, em vez de uma única mensuração, permitiu detectar as alterações na razão T/C de sinais opostos no início e no final do dia: os indivíduos com AOS apresentaram razão T/C maior que os controles na parte da manhã, enquanto que a razão T/C foi significantemente inferior à dos controles durante a noite. Conclusão: Os desequilíbrios no balanço anabólico-catabólico diurno sugerem que a AOS está associada a uma desregulação dos eixos hipotálamo-hipófise-adrenal e hipotálamo-hipófise-gonadal, potencialmente a causa subjacente de algumas das comorbidades neuropsicológicas observadas em pacientes com AOS.

Imbalance in the diurnal salivary testosterone/cortisol ratio in men with severe obstructive sleep apnea: an observational study.

INTRODUCTION: The complex relationship between sleep disorders and hormones could lead to alterations in the production of cortisol and testosterone in obstructive sleep apnea (OSA) patients. OBJECTIVE: The purpose of this study was to determine the diurnal trajectories of salivary free-testosterone, free-cortisol and their ratio (T/C). METHODS: Ten subjects newly diagnosed with OSA, based on nocturnal polysomnography evaluation and excessive daytime sleepiness, and seven matched controls were consecutively recruited. Cortisol and testosterone were measured in salivary samples collected upon awakening, at noon and in the evening. The psychometric evaluation of anxiety/depression and referred sexual function disturbances was performed to evaluate the presence of neuropsychological comorbidities. RESULTS AND CONCLUSION: The main finding was that OSA subjects displayed hypocortisolism upon awakening and a significant reduction in testosterone concentration in the evening in comparison with the control group, which has maintained the physiological testosterone and cortisol diurnal fluctuation, with higher hormone concentrations in the morning and lower concentrations in the evening. The use of data from multiple diurnal measurements rather than a single point allowed the detection of T/C ratio changes of opposite signs at the beginning and end of the day: the OSA subjects had a higher T/C ratio than the controls in the morning, while their T/C ratio was significantly lower than that of the controls in the evening. The imbalances in the anabolic-catabolic diurnal equilibrium suggest that OSA is associated with a dysregulation of the hypothalamic-pituitary-adrenal and hypothalamic-pituitary-gonadal axes, potentially an underlying cause of some of the neuropsychological comorbidities observed in OSA patients.

Bronchiectasis in cystic fibrosis and pregnancy.

Cystic fibrosis is an autosomal recessive disease with a prognosis determined by the extent of pulmonary lesions. Here we present a rare case of a patient diagnosed with cystic fibrosis in the pediatric service, but who came for the first time to the Pneumology Hospital of Iasi. Respiratory failure, recurrent pulmonary infections and associated metabolic modifications generate a high vital risk during pregnancy.

TB or not TB in HIV infection.

The progression of tuberculosis (TB) is significantly faster in patients with HIV infection. TB is also the main cause of death for HIV-infected individuals, resulting in fatality for 1 of 3 patients. We present the case of a 26-year-old male who arrived at the hospital having previously been diagnosed with HIV in 2014, but was not compliant to the ARV treatment prescribed. The patient presented with acute onset of fever, cough, hemoptysis and malaise. Investigations such as sputum samples and a lymph node biopsy revealed the presence of M. tuberculosis in optic microscopy, which led to a diagnosis of pulmonary and ganglionary TB. As one of the first opportunistic infections that occur in HIV-infected individuals, TB may be one of the earliest clues of an HIV infection. Current guidelines recommend that all individuals diagnosed with HIV should also undertake testing for TB infections.

A curious case of yellow nail syndrome.

The Yellow Nail Syndrome is a rare clinical entity, first described in 1967 by P.D. Samman and W.F. White. The triad slow-growing dystrophic yellow nails, lymphedema and chronic respiratory disorders is the typical manifestation of the disease but some variations have been described as well as associations with chylothorax, chylous ascites, intestinal lymphangiectasia, thyroid abnormalities, malignancies and immunoglobulin A (IgA) deficiency. We present a case of a 55-years-old woman that had an insidious onset of respiratory disorders and chronic sinusitis, suspected to be infectious throughout the hospitalizations, associated with therapeutically neglected autoimmune thyroiditis.

The influence of NaCl aerosols on weight and height development of children.

Saline aerosols resulted from natural or artificial sources are used for therapeutic environments. The paper presents the influence of the NaCl aerosols resulted in situ in dynamic halochambers, by structural reformation of saline aerosols in the presence of pentahydrol, on the increase in weight and height of children, as a result of systemically controlled practice of team and individual physical education games, with subjects of ages from 10 to 15. For reference, we used children of the same age and with the same physical education program, but whose activities were performed in open spaces, or in gym classrooms, without saline aerosols. Our study emphasized the fact that the NaCl aerosols formed in situ, in the atmosphere of the halochamber, at a rate of over 0.600 mg/m(3) of saline aerosols, enhanced the growth and weight gain at a higher rate in girls than in boys and at an obviously higher rate than that reported in the children who performed physical exercises in normal conditions, over a period of 3 years. All the data were statistically processed in order to evaluate the influence of the aerosols. The study reports the therapeutic benefits of salt exposure in children's development.

Asthma-like symptoms in a patient with rheumatoid arthritis and Adalimumab treatment.

After the introduction of anti-TNFα medication for treatment of autoimmune conditions, clinicians have investigated not only other possible uses for the drugs, but also less common side-effects and interactions with other pathologies. Despite some succes registered with Adalimumab as an antiinflammatory agent in severe asthma, there have been case reports of patients developing asthma or asthma-like symptoms following anti-TNFα therapy. The case presents a patient without previous family or personal history of respiratory or atopic conditions that developed bronchospasm immediately after the initiation of Adalimumab and Methotrexate treatment for rheumatoid arthritis. Despite the patient presenting asthma characteristics (expiratory wheezing, dry cough, partial reversibility at post bronchodilator test) and asthma medication alleviating simtomathology, biological markers (eosenophil granulocytes in sputum, serum IgE) for asthma are absent. The relationship between bronchospasm and medication and other possible causes for her respiratory symptoms are discussed.

Fatigue and serum testosterone in obstructive sleep apnea patients.

INTRODUCTION: Obstructive sleep apnea (OSA)-related fatigue is a common understudied symptom. Fatigue is associated with low serum testosterone level in non-OSA patients. No data are available about this association in OSA patients. OBJECTIVES: To investigate in adult obese males affected by OSA, the relationship between fatigue and serum testosterone in order to identify predictors for OSA-related fatigue. METHODS: Fifteen OSA patients and 15 control subjects participated. The parameters analyzed were serum testosterone morning concentration, polysomnography parameters, daytime sleepiness (Epworth Sleepiness Scale) and fatigue (Multidimensional Fatigue Inventory). Regression test was applied in order to show predictors of fatigue. Kruskal-Wallis test followed by post-hoc analysis was performed to test for differences between controls and OSA subgroups for testosterone, fatigue components and sleepiness. RESULTS: Mean testosterone level was 3.55 ± 0.7 ng/mL in the OSA group, significantly lower than in controls (4.26 ± 1.1 ng/mL, P = 0.049). An inverse correlation was found between testosterone and fatigue scores (P < 0.01). Furthermore, a statistically significant difference was found between the control group and the severe OSA subgroup for general fatigue, physical fatigue, reduced activity and mental fatigue. However, no significant differences were found between controls and mild OSA. Among all variables, testosterone was the only independent significant predictor of physical fatigue (t = -2.56, P = 0.033, R = 0.978, R(2) = 0.958) and reduced activity (t = -4.41, P = 0.002, R = 0.966, R(2) = 0.934) in the OSA patients. CONCLUSIONS: OSA-related fatigue was strongly associated with serum testosterone, together with OSA severity.

[Respiratory functional changes in pulmonary tuberculosis]. / Modificari functionale pulmonare asociate tuberculozei.

OBJECTIVES: The main objective of the study is to identify changes that occur in lung function in patients with pulmonary TB. The secondary objective is to determine the characteristics of bronchial obstruction associated with pulmonary TB. METHODS: There were included in the study patients with pulmonary TB diagnosed in Bacau Pneumology Hospital between January 2011 and March 2012. Data was collected on gender, age, origin, education, occupation, smoking, and TB case category. Expansion of lung lesions was assessed on chest radiographs. Lung function was measured by spirometry and bronchodilatator test. RESULTS: The study group included 84 patients with a mean age of 44.9 years, predominantly male (86.9%6) and rural (61.9%). Investigation revealed that smoking status was 23.81% nonsmoking, 22.62% former smokers and 53.57% smokers. 64.29% of patients were new cases of pulmonary TB, 15.47% relapse and 20.24% patients with chronic pulmonary TB. Assessment of ventilatory function found 58.33% of patients with respiratory defects. These were mainly restrictive (33.33%), mixed (17.86%) and obstructive (7.14%). Obstructive and mixed ventilatory defects are significantly associated with age over 40 years (chi2 = 4.70, r = 0.419, p = 0.036, 95% CI), male gender (chi2 = 8.14, r = 0.688, p = 0.027, 95% CI), smoking (chi2 = 11.251, r = 0.758, p = 0.032, 95% CI), category of chronic case of TB (chi2 = 11.25, r = 0.475, p = 0.0008, 95% CI) and radiological lung lesions extension (chi2 = 8.128, r = 0.658, p = 0.01293, 95% CI). CONCLUSIONS: Pulmonary TB is often associated wit significant functional changes, present since the early stages of the disease and which are often ignored. Early detection and proper treatment of TB could contribute to reducing the incidence of ventilatory defects associated with TB, and their rapid detection would allow better monitoring and thus improved quality of life of these patients. Extensive, multicenter, longitudinal studies are necessary to investigate and deepen knowledge of the functional consequences of tuberculosis.

History of BCG Vaccine.

Tuberculosis (TB) is still responsible for 2 million deaths every year despite being a treatable airborne infectious disease. "Consumption" and "Phthisis" were terms historically used to describe TB, which was responsible for one in four deaths in the 19th century. Due to its infectious nature, chronic progression and long treatment, TB is a great burden for society. Moreover the emergence of multi-drug resistant TB and the current TB-HIV epidemic has raised even greater concern. Treating and preventing TB has become a permanent challange since the ancient times. Bacille Calmette-Guérin (BCG) is the only vaccine available today and has been used for more than 90 years with astonishing safety records. However, its efficacy remains controversial. No universal BCG vaccination policy exists, with some countries merely recommending its use and others that have implemented immunization programs. In this article we review several important milestones of BCG vaccine development from the discovery till today.

Restoring the salivary cortisol awakening response through nasal continuous positive airway pressure therapy in obstructive sleep apnea.

Partial and largely conflicting data are currently available on the interplay between obstructive sleep apnea (OSA) and hypothalamus-pituitary-adrenal axis (HPA) activity in adult obese men. This study was performed to evaluate the daily trajectories of salivary cortisol, specifically with respect to the salivary cortisol awakening response (CAR), a common method used to assess HPA axis activity. The main findings of this study were that adult male obese subjects who were newly diagnosed with severe OSA showed the following: (1) a flattening of the CAR; (2) levels of cortisol at awakening that were lower than those of the controls; and (3) maintenance of the physiological circadian activity of the HPA axis, with the highest hormone concentrations produced in the morning and the lowest in the evening. This study was also designed to investigate the effects of 3 and 6 mos of treatment with continuous airways positive pressure (CPAP). CPAP use resulted in a significant recovery of the sleep patterns disrupted by OSA; moreover, mild neuropsychological signs of depression and anxiety in severe OSA patients were concomitantly progressively improved by CPAP treatment. Furthermore, this study reports that 3 and 6 mos of CPAP therapy restored the presence of CAR and was able to significantly reduce the difference in the morning cortisol levels between the OSA and control groups. In conclusion, we report here that compared with obese nonapneic matched controls, OSA patients present a dysregulation of HPA axis activity, as shown by the flattening of the diurnal pattern of cortisol production in response to repeated challenge due to hypoxia and sleep fragmentation. This dysregulation was especially detectable in the first hour after awakening and restored after 3 and 6 mos of treatment with CPAP.

Targeting multidrug-resistant tuberculosis (MDR-TB) by therapeutic vaccines.

Tuberculosis (TB) has scourged humankind for millennia, and latent infection affects nearly one-third of today's world population. The emergence of multidrug-resistant (MDR)-TB is a major global threat and reflects treatment failure of drug-sensitive disease. MDR-TB management is a burden for patients and society; success rates are unacceptably low with prolonged treatment duration. Mycobacterium tuberculosis (Mtb) possesses the ability to transform into a dormant state in which it can persist in the face of antimicrobial treatment and host defense. This sub-population of persisters is largely responsible for lengthy and difficult treatment. Targeting persistent bacilli could eventually improve the treatment success rate (currently 50-65 %) and shorten duration of treatment. A subset of therapies in the pipeline, termed therapeutic vaccines, use the host immune response to attack Mtb. The historical occurrence of an exacerbated host response has resulted in a negative perception of therapeutic vaccines. Thus, a renewed concept of immunotherapy is needed. We review current perspectives of immunotherapy in MDR-TB based on the knowledge of TB immunology and briefly discuss the profiles of several therapeutic vaccine products.

[Non-cystic bronchiectasis: pathogenic correlations between the parameters of body composition, systemic inflammation and respiratory function]. / Bronsiectazii non-chistice: corelatii patologice intre parametrii compozitiei corporale, sindromul inflamator sistemic cronic si functia respiratorie.

UNLABELLED: The causes of bronchiectasis may be idiopathic or secondary to pulmonary diseases. The consequences determined by this pathology are found on different levels. AIM: To determine the relationships between the parameters of body mass composition, chronic systemic inflammatory syndrome and lung function inpatients with bronchiectasis. METHOD: 35 patients with bronchiectasis diagnosed through HRCT (High Resolution Computer Tomography) and 35 patients with COPD were enrolled in the study. The protocol included the testing of all subjects, not in an acute period, to determine body mass composition, lung function and systemic inflammation. RESULTS: Modified parameters of body mass composition significantly correlated with those determined by the presence of inflammatory syndrome and alteration of lung function mainly for patients with bronchiectasis compared with patients with COPD. CONCLUSIONS: There is an important relationship between the parameters that were studied and this call for an individualized and targeted treatment that will lead to significant improvement of the general status of patients with bronchiectasis.

[Peripheral muscle dysfunction in chronic obstructive pulmonary disease]. / Afectarea musculaturii periferice in BPOC.

Although primarily a disease of the lungs, Chronic Obstructive Pulmonary Disease (COPD) associates systemic manifestations and comorbidities. The skeletal muscles function is restricted in COPD, because of decreased endurance and strength. Skeletal muscle weakness has a great clinical importance in COPD, as it is recognized to contribute independently to poor health status, reduced quality of life and increased mortality. The purpose of this paper is to describe the current knowledge of the structural and functional abnormalities of skeletal muscles in COPD and the possible physiopathologic determination of these dysfunctions. The understanding of these abnormalities is essential in development of new therapeutic strategies to combat muscle dysfunction in COPD, including the pulmonary rehabilitation programs.

[Association between the serum level of testosterone and other comorbidities in obstructive sleep apnea]. / Modificari ale nivelului seric de testosteron asociate comorbiditatilor sindromului de apnee în somn obstructiv.

Testosterone seems to play a role in the pathophysiology of OSAS but the mechanisms are not yet well defined. Research of this relationship has focused on two main assumptions: first case support the emergence of OSAS or augmentation of OSAS severity in men treated with testosterone for symptomatic hypogonadism; the second hypothesis suggest that serum testosterone deficiency is due to hypoxia and microarousals generated by OSAS with direct impact on hypothalamic-pituitary-gonadal axis. The correlation between sleep apnea and androgenic disorders should be considered in the light of the intervention of many other factors which can act as confounding factors: age, obesity and other associated pathologies (chronic lung disease, smoking status). Many studies conducted so far on this interrelation (sleep apnea, endocrine system) have ignored these factors. In most cases CPAP (continuous positive airway pressure) therapy revert low serum testosterone levels to normal levels. Depressive status and fatigue, as OSAS consequences associated with hypogonadism have been reported in the literature and may have clinically significant aspects due to summary effect, with notable improvement after CPAP therapy avoiding adverse effects of hormonal or antidepressant treatment. The clinical implications and major consequences of association between androgen dysfunction and sleep apnea syndrome require a correct management in the recognition and treatment of obstructive sleep apnea syndrome associated with comorbidities.

[Quality of sleep in students]. / Calitatea somnului la studenti.

Sleep quality is an important factor involved in students' learning process. Using different methods, actual studies suggest that complaints about sleep problems are common in young medical students. The aim of this study was to evaluate if is any relation between factors like medium and lifestyle among students of the University of Medicine and Pharmacy "Grigore T Popa" from Iasi. The study group included 30 students (2 of them were excluded) who performed a polisomnography, self reported Epworth questionnaire and two weeks sleep diary. Coffee, energy drinks, green and black tea and alcohol intake were recorded. In our evaluation it was used sleep disturbance index (SDI), for sleep quality description. In those two weeks, the mean sleep hours was 7.8 (95% CI 7.6-8), greater in female than in male. The results suggest a significant correlation between psychical excitants and sleep fragmentation. More, excessive daytime somnolence declared is not in concordance with sleep quality observed in sleep recorded with polysomnography. It looks to be in correlation with bad sleep habits and psychical excitants intake.