Halotherapy for Chronic Respiratory Disorders: From the Cave to the Clinical.

CONTEXT: Halotherapy (HT) is a form of speleotherapy, a respiratory therapy involving breathing inside a cave, and its therapeutic environment is similar to that of a natural salt cave. Natural crystallized salt is inhaled via aerosols or from the environment directly to enhance breathing and respiratory health-related quality of life (HRQoL). Clinicians need to be aware of its potential benefits, with relatively few or no adverse effects and consider its use an adjuvant therapy for standard care. OBJECTIVE: The current review intended to compile the existing literature on HT's use in various chronic respiratory diseases. It examines the use of dry salt inhalers; the use of saline nebulizer therapy is already well established in the literature. DESIGN: The research team performed a literature review to identify all articles published in the English language between January 1980 and December 2018 that used HT or heliotherapy and speleotherapy in the title. Pseudonyms such as salt cave therapy and salt mine therapy were also included. The source of data was the National Library of Medicine's MEDLINE/PubMed. SETTING: Literature search took primarily from the main campus of Brookdale University Hospital Medical Center and the Touro College of Osteopathic Medicine. RESULTS: Literature search and review yielded a total of 13 manuscripts that were completely assessed and incorporated into this review. Overwhelmingly studies comparing various methods of halotherapy showed improvement in various pulmonary function measures including forced expiratory volume in one second, forced vital capacity and peak expiratory flow. Other measures were also seen to improve such as HRQoL as assessed by questionnaires. CONCLUSIONS: HT has been found to have a positive effect on patients suffering from chronic respiratory diseases, improving mucociliary elimination and lung function in common chronic respiratory diseases and also HRQoL. Currently, no official guidelines exist on the use of HT in the form of salt rooms (halo chambers) or dry powder inhalers, but evidence exists for its use as a possible adjuvant therapy. More structured research in the form of randomized clinical trials is required.

Health Disparities in Patients with Pulmonary Arterial Hypertension: A Blueprint for Action. An Official American Thoracic Society Statement.

BACKGROUND: Health disparities have a major impact in the quality of life and clinical care received by minorities in the United States. Pulmonary arterial hypertension (PAH) is a rare cardiopulmonary disorder that affects children and adults and that, if untreated, results in premature death. The impact of health disparities in the diagnosis, treatment, and clinical outcome of patients with PAH has not been systematically investigated. OBJECTIVES: The specific goals of this research statement were to conduct a critical review of the literature concerning health disparities in PAH, identify major research gaps and prioritize direction for future research. METHODS: Literature searches from multiple reference databases were performed using medical subject headings and text words for pulmonary hypertension and health disparities. Members of the committee discussed the evidence and provided recommendations for future research. RESULTS: Few studies were found discussing the impact of health disparities in PAH. Using recent research statements focused on health disparities, the group identified six major study topics that would help address the contribution of health disparities to PAH. Representative studies in each topic were discussed and specific recommendations were made by the group concerning the most urgent questions to address in future research studies. CONCLUSIONS: At present, there are few studies that address health disparities in PAH. Given the potential adverse impact of health disparities, we recommend that research efforts be undertaken to address the topics discussed in the document. Awareness of health disparities will likely improve advocacy efforts, public health policy and the quality of care of vulnerable populations with PAH.

Diagnosing and managing scleroderma-related pulmonary arterial hypertension.

Scleroderma is an uncommon autoimmune disease of unknown cause that may affect any organ system in the body. Patients with scleroderma are prone to developing pulmonary complications, including pulmonary arterial hypertension (PAH), that are the leading cause of death in this population. This article describes scleroderma-related PAH and its diagnosis and management.

[The correlation between testosterone levels and C-reactive protein in acute bacterial epididymo-orchitis]. / Korelacja stezenia testosteronu i bialka C-reaktywnego w ostrym zapaleniu jadra i najadrza.

UNLABELLED: Acute bacterial epididymo-orchitis is common urological condition that usually originates from ascending infection of lower urinary tract. It is characterized by infection of testis combined with spermatogenesis and steroidogenesis impairment. There is also a component of local and systemic inflammation. AIM: The aim of this study was to assess the effect of systemic inflammation associated with acute epididymo-orchitis on testis steroidogenesis. MATERIALS AND METHODS: 30 patients with acute bacterial epididymoorchitis treated in our ward without any oncologic involvement or other systemic inflammatory conditions were considered for the study. Total serum levels of testosterone and C-reactive protein measured within 12 hours of admission. RESULTS: Low total testosterone levels regarding to random laboratory population norms were noticed in 11 patients. Diminished serum total testosterone levels regarding to medium age levels were identified in 24 patients (80%). 29 patients had serum CRP levels elevated what gives average 22x fold. There is a statistically significant negative correlation between serum total testosterone levels and CRP serum levels were found (R - 0.75; p<0.000002 Spearman's correlation). CONCLUSIONS: There is a strong influence of ongoing systemic inflammation caused by bacterial infection on steroidogenesis in testis in acute epididymo-orchitis patients.

Pulmonary arterial hypertension: a current review of pharmacological management.

Pulmonary hypertension (PHTN) is a rare and devastating disease characterized by progressive increases in pulmonary arterial pressure and pulmonary vascular resistance, which eventually leads to right ventricular failure and death. At present there is no cure for pulmonary arterial hypertension (PAH); however over the past decade targeted pharmaceutical options have become available for the treatment of PAH. Prior to evaluation for therapeutic options a definitive diagnosis of pulmonary arterial hypertension must be made via comprehensive physical exam and definitive diagnostic testing. Screening test of choice remains echocardiography and gold standard for definitive diagnosis is right heart catheterization. Once the establishment of a diagnosis of PAH is made therapeutic options may be a possibility based on a diagnostic algorithm and disease severity of the PAH patient. There are different classes of medications available with different mechanisms of actions which net a vasodilatory effect and improve exercise tolerance, quality of life as well and survival.

"Saw-tooth sign" in upper airway disorders­a case report.

Spirometry flow-volume loop measurement is the screening test of choice to rule out obstructive lung diseases. Flow oscillations occasionally seen on flow volume loops, referred to as a "saw-tooth" sign, are thought to be due to an upper airway obstructive processes associated with upper airway collapsibility. Widely described in obstructive sleep apnea syndrome, flow oscillations have also been linked to many other upper airway pathologies. The mechanism by which flow oscillations occur is centered on the inspiratory and expiratory flow of air. It has been theorized that the mechanism of flow oscillations result from rapid intermittent changes in driving pressure or airway resistance. Since visual inspection of the flow volume loop can reveal presence of flow oscillations clinicians should be aware of this phenomenon and the presence of flow loop oscillations should clue physicians to rule out upper airway pathology.

Effects of pulmonary rehabilitation on Fatigue Severity Scale in patients with lung disease.

INTRODUCTION: Fatigue is a known symptom of advanced lung disease and impacts quality of life and psychological health. Many of these patients undergo pulmonary rehabilitation as part of their therapy. Understanding the effect of pulmonary rehabilitation on fatigue in these patients is important, as one may be able to design more focused rehabilitation programs. The aim of this study is to evaluate the effect of pulmonary rehabilitation on fatigue as measured by the Fatigue Severity Scale (FSS) in patients with advanced lung disease. MATERIAL AND METHODS: Patients were enrolled in a standardized 6 week pulmonary rehabilitation program. They were asked to complete questionnaires to evaluate their self-reported fatigue (FSS), and depression as measured by Geriatric Depression Scale (GDS). The GDS is a self-reported assessment tool used to identify depression in patients. The FSS is a validated instrument that indicates a perception of fatigue that might require medical intervention. Participants completed questionnaires both at baseline and after completing the standardized pulmonary rehabilitation program. Data was analyzed in Statistical Analysis System (SAS). The change in FSS was evaluated using the Wilcoxon signed-rank test. P-values < 0.05 were considered statistically significant. RESULTS: 21 patients (12 females; 9 males; mean age 64.3 ± 11.2 yrs) were considered for the study. Pre-pulmonary rehabilitation FSS scores ranged from 1.6 to 6.7 (mean score of 4.6 ± 1.7). Post pulmonary rehabilitation FSS scores ranged 1.0 to 6.2 (mean score of 3.9 ± 1.6). The median pre-rehabilitation FSS was 5.3 (inter quartile range; Q1-Q3: 3.0-6.1), and median post rehabilitation FSS was 3.9 (inter quartile range; Q1-Q3: 2.6-5.1). There was a significant decrease in FSS scores after completing pulmonary rehabilitation program (p < 0.0208). There was a decrease in GDS (pre-rehabilitation, mean: 5.5 ± 3.6; post-rehabilitation, mean: 4.2 ± 2.9), but this decrease was not statistically significant. The change in GDS correlated with the change in FSS (Spearman Correlation Coefficient 0.525, p < 0.0146). CONCLUSIONS: Patients with advanced lung disease reported a measurable component of fatigue. Participating in pulmonary rehabilitation resulted in significant improvement in patient's self-reported fatigue severity. Further studies are necessary to evaluate and design interventions to improve fatigue in in the setting of advanced lung disease.

A rare case of endobronchial and lung metastasis in basal cell carcinoma.

Basal cell carcinoma (BCC) is the most common skin cancer, but rarely metastasizes. This article describes diagnosis and treatment of an extremely rare case of BCC metastasizing to the lung and endobronchial tissue.

A Workout to Remember: CrossFit-Induced Vertebral Artery Dissection.

Vertebral artery dissection (VAD) is a cause of brain stem stroke in the younger population and is commonly associated with trauma, sudden neck movement, or chiropractic manipulations. In this case, a 28-year-old male with a non-significant past medical history who recently started a CrossFit boot camp presented to the emergency department with right-sided neck pain, dysarthria, mild right gaze paresis, right dysmetria, and right facial droop with symptoms of Horner's syndrome. Imaging results revealed an age-indeterminate left lateral cerebellar infarct with right VAD. The goal of management is to prevent stroke, which is done with anticoagulation and potentially thrombolytic therapy if there are no contraindications. The patient received thrombolytic therapy and was treated with conservative management. The prognosis is good for patients who survive the initial dissection and are treated in this manner. It is important to obtain a thorough history of young and healthy patients who present with concerning neurologic symptoms so that precipitating activities are not missed.

Primary Peritoneal Carcinoma: A Rare Malignancy Presenting a Diagnostic Challenge.

With the advancement in technologies and the development of a vast variety of tests, diagnosing diseases has become relatively easy. However, certain diseases are challenging to diagnose due to their similarities with other disease processes. Primary peritoneal carcinoma (PPC) is one of the infrequent tumors that has a resemblance to an ovarian tumor, often making it hard to diagnose. The symptoms are non-specific, and by the time primary peritoneal cancer is diagnosed, the patient is usually at an advanced stage. Although diagnosis might be suspected based on presenting symptoms, it is rarely confirmed with symptomatology alone, requiring additional tumor markers or radiological studies. Sometimes it is diagnosed after surgical removal of the lesion. Several similarities have been described between PPC and ovarian cancer, with some studies explaining the differences as well. We highlight the importance of careful interpretation of imaging studies for the timely diagnosis of PPC. However, several factors can interfere with the analysis of test results leading to delays in diagnosis and management. Interpretation of imaging becomes difficult, especially in patients with significant ascites.

Hematological manifestations and complications of COVID-19.

The virus SARS-CoV-2 commonly causes self-resolving, flu-like illnesses in the majority of patients, but a critical illness can be seen in 5% of cases - especially in the elderly population or in patients with multiple comorbidities. When COVID-19 is severe, it can cause pneumonia and hypoxemic respiratory failure, and can progress to viremia involving multiple organ systems. It causes significant cytopenia, mainly severe lymphopenia, and excessive exhaustion of CD8+ T cells, resulting in an immunocompromised state and cytokine storm. Furthermore, COVID-19 can commonly be complicated with acute thrombotic events, including venous thromboembolism, acute stroke, acute myocardial infarction, clotting of hemodialysis and extracorporeal membrane oxygenation (ECMO) catheters, and acute limb ischemia. This makes SARS-COV-2 a unique virus with an undiscovered pathophysiology. Therefore, patients with COVID-19 need close monitoring of their symptoms and laboratory parameters, and early hospitalization and treatment in severe cases. Early identification of severe cases and the abovementioned complications of COVID-19 could decrease the morbidity and mortality caused by the disease. In the study, we summarize what is currently known about the hematological manifestations and complications of COVID-19.

Subacute Stent Thrombosis in a Patient With COVID-19 Despite Adherence to Antiplatelets.

The coronavirus disease 2019 (COVID-19) creates a significant burden on the cardiovascular system. Moreover, diagnosing coronary artery disease in patients with COVID-19 may be clinically challenging. Herein, we present a case of in-hospital stent thrombosis and thrombotic occlusion of the right coronary artery after initial revascularization and adherence to antiplatelet therapy.

Wellens' Syndrome in the Setting of the 2019 Novel Coronavirus (COVID-19).

The novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-Cov2), is the causative pathogen of coronavirus disease 2019 (COVID-19), which is primarily described as a respiratory illness. However, a wide array of cardiovascular complications has also been described in the setting of COVID-19. Wellens' syndrome, also regarded as a left anterior descending coronary T-wave syndrome, is an electrocardiography (EKG) pattern that indicates critical proximal left anterior descending (LAD) artery stenosis. It is characterized by deeply inverted T-waves or biphasic T-waves in the anterior precordial chest leads in a patient with unstable angina. Patients typically present with symptoms consistent with acute coronary syndrome. To our knowledge, we present the first case of Wellens' syndrome in a patient with a COVID-19 infection. Furthermore, this case describes stenosis of the left circumflex artery, a variant of the unusual angiographic findings associated with Wellens', as it is usually associated with occlusion of the proximal LAD. The pathophysiology of cardiovascular complications associated with COVID-19 is not well-understood; nevertheless, it was reported that mortality from coronary artery disease (CAD) complications is significantly higher in these patient populations. Healthcare providers should also be aware of identifying Wellens' syndrome, as urgent coronary angiography is superior to stress testing.

Wellens' Syndrome Presenting as Epigastric Pain and Syncope: An Unusual Presentation.

Wellens' syndrome, also regarded as left anterior descending coronary T-wave syndrome, is an electrocardiography (EKG) pattern that indicates critical proximal left anterior descending artery (LAD) stenosis. It is characterized by deeply inverted T-waves or biphasic T-waves in the anterior precordial chest leads in a patient with unstable angina. Patients typically present with symptoms consistent with acute coronary syndrome. We present a unique case of Wellens' syndrome with no angiographic findings of significant stenosis in the proximal LAD but with significant occlusion of the proximal circumflex artery and initial presentation with a chief complaint of epigastric pain and syncope. Physicians need to recognize these characteristic EKG changes during the pre-infarction stage, as they represent myocardial necrosis. Many of these patients eventually develop extensive anterior myocardial infarction with marked left ventricular dysfunction and death if coronary angiography and coronary revascularization are not performed within a few weeks. If Wellens' is seen, patients should undergo urgent cardiac catheterization.

A Broken Heart: Cardiac Arrest As the Initial Presentation of Myasthenic Crisis.

Myasthenic crisis is a life-threatening condition commonly associated with respiratory failure and may present in unusual ways. However, there is paucity in the literature about the cardiac manifestations of myasthenia gravis. We present a case of a 61-year-old male who presented to the emergency room with upper respiratory infection symptoms who soon thereafter suffered sudden cardiac arrest. He was found to have shortened PR interval pre and post arrest onelectrocardiogram (EKG). Only past medical history, discovered post cardiac arrest, was myastenia gravis. All other causes of cardiac arrest were ruled out, and it was deemed to be due to a manifestation of myastenia gravis. The patient was treated with intravenous steroids and plasmapheresis with resolution of shortened PR interval. It is hypothesized that striatial muscle antibodies may trigger inflammation in cardiac muscle and cause conduction abnormalities. In addition, anti-Kv1.4 antibodies have been associated with EKG abnormalities, including QT prolongation and T-wave inversion. To our knowledge, we are the first to report myasthenic crisis manifesting with isolated cardiac arrest with pulseless electrical activity and a shortened PR interval.

Disseminated Varicella-Zoster Virus Infection Complicated by Encephalitis and Ramsay Hunt Syndrome in an HIV Patient.

Varicella-zoster virus (VZV) is a human α-herpesvirus which cause primary varicella infection (chicken pox) or herpes zoster infection (shingles) after reactivation of the dormant virus. VZV infection is usually self-limited but disseminated infection can be seen in immunocompromised individuals. It can also get complicated by central nervous system (CNS) involvement. We describe a case of a 51-year-old male with human immunodeficiency virus (HIV) who presented with altered mental status and deficits in his right-sided cranial nerves of VI, VII, and VIII. The patient also had disseminated vesicular-pustular rash all over his body at different stages of healing. A diagnosis of disseminated VZV infection complicated by encephalitis and Ramsay Hunt syndrome was made and the patient was treated with intravenous acyclovir and oral prednisone with a rapid improvement. The coexistence of these conditions is rare. The purpose of this report is to increase awareness of the coexistence of these two conditions in HIV infected patients.

Narrow Escape: A Novel Approach to the Endovascular Treatment of Superior Vena Cava Syndrome Secondary to Pacemaker Leads with Excellent Long-term Outcomes.

Pacemaker or defibrillator placement is a common procedure done in more and more patients due to increased longevity and the prominence of cardiac disease. With more indications for cardiac implantable electrode devices, the devices themselves have evolved into more complex structures with more leads. The mechanical stress, risk of infection, and decreased blood flow through the superior vena cava (SVC) put patients at risk for SVC obstruction. Herein, we present a rare case of complete SVC obstruction secondary to fibrosis due to pacemaker leads which was treated with venoplasty and showed excellent long-term results. We also review the current literature on different approaches to treating SVC obstruction in this group of patients.

Pulmonary arterial hypertension in the elderly: Clinical perspectives.

Pulmonary hypertension (PH) is a rare and devastating disease characterized by progressive increases in pulmonary arterial pressure and pulmonary vascular resistance, which eventually leads to right ventric-ular failure and death. Pulmonary arterial hypertension (PAH) (World Health Organization Group I), a subset of PH, and may be idiopathic in nature or associated with other systemic conditions and is thought to most commonly effect women, the majority of whom are of childbearing age. However, PAH in the elderly population is being increasingly diagnosed creating clinical considerations that had once not been considered. Often in an elderly population the diagnosis of PAH may be delayed due to chronic comorbid conditions such as coronary artery disease or other dyspneic conditions. Though survival and clinical outcomes have improved, the elderly population continues to have disproportionately lower survival rates. High clinical suspicion of PAH warrants a complete diagnostic workup with right heart catheterization. Upon diagnosis, PAH specific therapy should be initiated with possible drug interactions in mind. Adjuvant pulmonary rehabilitation should be considered as a conservative measure with definitive results. Finally, psychosomatic aspects of the disease should also be considered in elderly populations.

Paraneoplastic Pemphigus: An Indication for Treatment in Chronic Lymphocytic Leukemia.

Paraneoplastic disorders are rare multiorgan diseases associated with hematological malignancies such as chronic lymphocytic leukemia (CLL). Some of these paraneoplasms manifest as cutaneous lesions, appearing as a simple rash, ulcers or skin thickening. The pathogenesis for this process has been described as development of certain autoimmune reactions against cell wall antigens and proteins. An example is paraneoplastic pemphigus (PNP) which manifests as cutaneous bullae. Bullae may occur anytime during the course of the malignancy i.e. acute phase or remission. Diagnosis involves evaluation of clinical findings, serology and presence of characteristic histological findings. Its pathogenesis is described as development of auto-antibodies against cell junctional and basement membrane proteins. Presence of paraneoplasms has been associated with poorer prognosis and increased mortality in hematological malignancies including CLL. Currently, there are established indications for the treatment of CLL; however, presence of paraneoplasms as an indication for treatment is unclear. Patients with paraneoplasms who underwent expeditious treatment have exhibited better clinical outcomes. Herein we describe a case of a CLL patient in remission presenting with PNP and its response to treatment.