Maternal age and asthma in Latino populations.

BACKGROUND: Younger maternal age at birth is associated with increased risk of asthma in offspring in European descent populations, but has not been studied in Latino populations. OBJECTIVES: We sought to examine the relationship between maternal age at birth and prevalence of asthma in a nationwide study of Latino children. METHODS: We included 3473 Latino children aged 8-21 years (1696 subjects with physician-diagnosed asthma and 1777 healthy controls) from five US centres and Puerto Rico recruited from July 2008 through November 2011. We used multiple logistic regression models to examine the effect of maternal age at birth on asthma in offspring overall and in analyses stratified by ethnic subgroup (Mexican American, Puerto Rican and other Latino). Secondary analyses evaluated the effects of siblings, acculturation and income on this relationship. RESULTS: Maternal age < 20 years was significantly associated with decreased odds of asthma in offspring, independent of other risk factors (OR = 0.73, 95% CI: 0.57-0.93). In subgroup analyses, the protective effect of younger maternal age was observed only in Mexican Americans (OR = 0.53, 95% CI: 0.36, 0.79). In Puerto Ricans, older maternal age was associated with decreased odds of asthma (OR = 0.65, 95% CI: 0.44-0.97). In further stratified models, the protective effect of younger maternal age in Mexican Americans was seen only in children without older siblings (OR = 0.44, 95% CI: 0.23-0.81). CONCLUSION AND CLINICAL RELEVANCE: In contrast to European descent populations, younger maternal age was associated with decreased odds of asthma in offspring in Mexican American women. Asthma is common in urban minority populations but the factors underlying the varying prevalence among different Latino ethnicities in the United States is not well understood. Maternal age represents one factor that may help to explain this variability.

The role of LTA4H and ALOX5AP genes in the risk for asthma in Latinos.

BACKGROUND: Leukotrienes play an important role in allergic and inflammatory diseases, but reports on the involvement of arachidonate 5-lipoxygenase-activating protein (ALOX5AP) and leukotriene A(4) hydrolase (LTA4H) in asthma have been inconclusive. OBJECTIVE: To determine whether polymorphisms in ALOX5AP and LTA4H genes are risk factors for asthma in two different Latino groups: Mexicans and Puerto Ricans. METHODS: The LTA4H gene was sequenced in individuals from both groups to identify novel polymorphisms. Single-nucleotide polymorphisms (SNPs) in the ALOX5AP and LTA4H genes were analysed for associations with asthma and asthma-related phenotypes in 687 parent-child trios of Mexican and Puerto Rican origin. RESULTS: In LTA4H, five previously unknown polymorphisms were identified. Two SNPs within LTA4H (rs17525488 and rs2540493) were protective for asthma in Latinos (P=0.007 and 0.05, respectively). Among the Mexican patients, LTA4H polymorphisms were associated with baseline lung function and IgE levels. For ALOX5AP, the minor allele at SNP rs10507391 was associated with protection from asthma (odds ratio=0.78, P=0.02) and baseline lung function (P=0.018) in Puerto Ricans. A gene-gene interaction was identified between LTA4H (rs17525488) and ALOX5AP (rs10507391), (P=0.003, in the combined sample). CONCLUSION: Our results support the role of LTA4H and ALOX5AP variants as risk factors for asthma in Latino populations.

Flow-volume loops: clinical correlation

Flow volume loops are an essential part of spirometry testing. Their appearance can give information that can be helpful in the differential diagnosis of a patient's clinical condition. We present two clinical scenarios in which careful evaluation of the flow-volume loop gives an insight into the cause of the disease process.

Hepatopulmonary syndrome

This is a report of a 56-year-old male who was admitted to the Intensive Care Unit of the San Juan V.A. Medical Center with altered mental status and severe hypoxemia. He was diagnosed with severe hyponatremia and hepatopulmonary syndrome.

Acute respiratory distress syndrome in the trauma intensive care unit: the other view

OBJECTIVE: To study the timeliness of the diagnosis of patients with acute respiratory distress syndrome (ARDS)/acute lung injury (ALI) at the Puerto Rico Trauma Center (PRTC) and to determine the overall 28 day mortality for ARDS during the study period. METHOD: A retrospective review of all admissions to the Trauma Intensive Care Unit (TICU) from August 2000 to August 2001 was done. Patients with the diagnosis of ARDS/ALI were selected, records examined, and clinical data obtained for analysis. FINDINGS: Of the 537 patient admitted to the PRTC, 236 patient were admitted to TICU. Of these, 17 patients were identified as having hypoxemic ratios below 200 and 13 patients were identified as having ARDS as established by the American-European Consensus Conference of 1994. Their mean age was 41 years, the main cause of ARDS was due to pulmonary contusion due to blunt chest trauma. The 28-day survival for this group was 43 per cent. Subgroup analysis showed that there was 86 per cent mortality when the polytraumatized patient developed sepsis. CONCLUSION: The majority of the cases of ARDS were correctly identified as such by caregivers at the time of diagnosis. Mortality as predicted by Injury Severity Score in our ARDS patients' correlates with overall mortality in our TICU. Mortality in this group is lower than that of reported literature, in sharp contrast to our medical ICU counterparts.

Acute lung injury/acute respiratory distress syndrome: a need for education

OBJECTIVE: To examine the timeliness of the diagnosis of patients with ALI/ARDS at the San Juan VA Medical Intensive Care Unit. We were also interested in determining the incidence and the overall 28-day mortality for ARDS during the study period. METHODS: Retrospective record review of all admissions to the San Juan Veterans Affairs Medical ICU during a two-year period (1997-1998). RESULTS: During the study period, 587 patients were admitted to the medical ICU. All had APACHE II scoring performed during their first 24 hours of admission. Twenty-three patients were found to have an A-a gradient of 350 or less. However, two patients were later identified as having radiographic changes compatible with Congestive Heart Failure and were excluded from the study. The incidence of ALI/ARDS was found to be 3.6 per cent at our institution. Of the 21 patients with ARDS, in only 4 the diagnosis of ARDS was documented on their charts. CONCLUSION: Our findings suggest that education in the recognition of ARDS should be aggressively done. In order to implement the recently published successful strategies in the mechanical ventilation of patients with ARDS, it should be first recognized. Our patients need it.

Legionnaires' disease: a rare entity in Puerto Rico?

Legionnaires' disease is a severe, often fatal pneumonia, caused by Legionella pneumophila. Its incidence is reported about 6%. In Puerto Rico, there is no data available of the prevalence of Legionnaires' disease. A case of Legionnaires' is presented as well as data to support that the prevalence in our Island is higher than the reported elsewhere.

Substituted judgement: should life-support decisions be made by a surrogate?

OBJECTIVE: To evaluate the utility of the substituted judgement standard in terminally ill patients by determining agreement between patients, family proxies and physicians. BACKGROUND: Several studies have addressed the utility of substituted judgement, showing conflicting data whether surrogates are accurate predicting patient's wishes. METHODS: Patients with acquired immunodeficiency syndrome, congestive heart failure, chronic liver disease admitted to the San Juan Veterans Affairs Medical Center in Puerto Rico from November 1997 to February 1998 were evaluated. A questionnaire presented three hypothetical situations on withholding and withdrawal of life-support and CPR. The percent agreement was used as a measure of concordance between choices made by physician, surrogate and patients. RESULTS: Twenty patients met inclusion criteria (5 chronic liver disease, 9 heart failure, 6 AIDS). Relatives had a higher percent of agreement as compared to physicians in all vignettes. Even though, none did better than chance in predicting patient's wishes (k < 0.4). There was a tendency for relatives not to provide a wanted life-support measure, and for physicians to provide an unwanted life-support measure. CONCLUSION: The poor agreement between patients and surrogates suggests that substituted judgement is not an accurate tool to make end-of-life decisions. These findings, although similar to previous published studies, are unique because the direction of discrepant responses is opposite to the findings of studies published elsewhere. These results could reflect religious, cultural and socioeconomic differences.

An unusual cause of cyanosis in a patient with a carcinoid tumor.

We report the second case of a right-to-left interatrial shunt due to a carcinoid tumor, which was successfully corrected by surgery. The patient had closure of a patent foramen ovale and tricuspid valve replacement. One and a half years after surgery, the patient had no symptoms related to heart disease.

Synchronous pulmonary cryptococcosis and histoplasmosis.

A chronically immunosuppressed patient receiving oral steroid therapy had a cavitary lesion; both Histoplasma capsulatum and Cryptococcus neoformans were found in samples of respiratory secretions. C neoformans was also found in specimens taken from skin lesions and blood. This is the first reported instance of synchronous infection by these two fungi.

Bronchiectasis and homozygous (P1ZZ) alpha 1-antitrypsin deficiency in a young man.

Pulmonary complications of alpha 1-antitrypsin deficiency are most commonly manifested by panlobular emphysema. This report describes histologically proven bronchiectasis in a 21 year old man with massive haemoptysis and homozygous deficiency of alpha 1-antitrypsin. Neither panlobular emphysema nor cirrhosis of the liver were present. Bronchiectasis must be considered part of the spectrum of the pulmonary pathology that may be encountered in individuals with alpha 1-antitrypsin deficiency.

Pulmonary coccidioidal pseudomycetoma.

Coccidiomycosis is rarely associated with a pulmonary mycetoma. We report a patient with progressive cavitary coccidiomycosis, whose initial radiographic and clinical appearance simulated a mycetoma. Examination of the surgically resected lung showed necrotizing Coccidioides immitis granulomas with spherules and arthroconidialike structures, but no evidence of a mycetoma. We propose the term pulmonary coccidioidal pseudomycetoma as the best descriptor for this patient's clinical, radiographic, pathologic, and microbiologic presentation.