Endoscopic bronchial ultrasound in mediastinal staging of lung cancer

Lung cancer is a global healthcare concern with a low 5-year survival rate and a high proportion of advanced-stage cases at diagnosis. In the absence of distant metastasis, the most important prognostic marker is mediastinal lymph node involvement. Timely diagnosis and staging improves prognosis, making rapid, safe, and accurate investigation essential. Endoscopic bronchial ultrasound (EBUS) is a minimally invasive technique which allows for ultrasound-guided transbronchial needle aspiration (TBNA) during bronchoscopy, with cytological sampling of several intrathoracic groups of lymph nodes. EBUS reduces need for open surgical biopsy, with good sensitivity and specificity and excellent safety profile. This article reviews current evidence regarding use of EBUS in lung cancer staging, including its role in other intrathoracic malignancies.eviews current evidence regarding use of EBUS in lung cancer staging, including its role in other intrathoracic malignancies.peer-reviewe

Current GOLD recommendations and its implementation within hospitalised COPD patients in Malta

In 2012, Global Initiative for Chronic Obstructive Lung Disease (GOLD) revised their classification of Chronic Obstructive Pulmonary Disease patients, incorporating spirometry, symptoms and recent exacerbations. The sims and objectives was to assess if patients admitted with an exacerbation of COPD were properly staged prior to the admission, and whether their treatment on presentation was in accordance with GOLD recommendations. All patients admitted to Mater Dei Hospital, Malta with a COPD exacerbation during February, May and August 2013 were studied. Spirometry was considered relevant if performed within the previous two years. The mMRC score of each patient, the number of exacerbations over the previous 12 months, and patient co-morbidities were also recorded.peer-reviewe

Spontaneous pneumomediastinum in idiopathic pulmonary fibrosis

Spontaneous pneumomediastinum is an uncommon occurrence and is usually self-limiting. Spontaneous pneumomediastinum is the presence of free air around mediastinal structures and is thought to be secondary to alveolar or honeycomb cyst rupture due to raised intrapulmonary pressure on coughing, blunt force trauma to the chest, asthma, various types of interstitial lung diseases, including interstitial pneumonia associated with connective tissue diseases, including dermatomyositis and rheumatoid arthritis. We herein report a rare case of spontaneous pneumomediastinum with thoracic-wall subcutaneous emphysema occurring in an elderly gentleman with idiopathic pulmonary fibrosis (IPF).peer-reviewe

Pulmonary rehabilitation in chronic obstructive pulmonary disease : outcomes in a 12 week programme

Objective. The optimal time-frame for pulmonary rehabilitation (PR) in patients diagnosed with chronic obstructive pulmonary disease (COPD) is still debated. A 12 week programme was designed looking at whether the benefits were reached at or before a 12 week period of PR for COPD patients. Method. Seventy-five patients (59 males, 16 females) aged 40 75 years were referred from the local general hospital in Malta. Baseline assessments were carried out on all patients 2 weeks before initiation of the programme. Sixty patients were eligible to start a twice-weekly, 12 week multidisciplinary programme delivered after the screening process. The Six-Minute Walk Test (6MWT), dyspnoea score using the Borg scale, spirometry testing, plethysmography, COPD Assessment Tool (CAT) score, St George's Respiratory Questionnaire (SGRQ) and Hospital and Anxiety scale score were monitored at 4 weekly intervals throughout the 12 weeks of PR for these COPD patients. Results. The 6MWT distance increased by a mean total of 132.45 m (p < 0.001) by 12 weeks, with the highest change recorded in the first 4 weeks for the milder COPD patients. Lung function test improvements were marginal. Borg scale readings at rest and following exertion decreased significantly from weeks 0 to 4 but remained fairly constant thereafter. The Body mass index, airway Obstruction, Dyspnoea, and Exercise capacity (BODE) index, SGRQ and CAT score values decreased significantly throughout the weeks irrespective of the initial Medical Research Council score. Anxiety scoring decreased significantly by 12 weeks, while the depression rating improved by 8 weeks. Conclusion. These findings show that 12 weeks of PR in this cohort of COPD patients resulted in clinically significant changes in functional outcome measures which are supported by statistically significant changes in health-related quality of life measures. In milder COPD cases, by 4 weeks of PR gains in exercise tolerance had already resulted. The more severe group required more time to obtain improvements. Therefore, hospitals could organize shorter PR programmes for larger numbers of patients with milder COPD.peer-reviewe

Total serum IgE and specific IgE levels in 10-15 year old children with respiratory symptoms and healthy controls in Sicily and Malta

Introduction: The RESPIRA study (EU Funded-Italia-Malta) was performed in the district of Gela (Southern Sicily) and Malta in 2012/3 in 10-15 years old schoolchildren (n=2,047) by means of standard respiratory questionnaires (ISAAC),and clinical exam of case and control subjects. Aims and Objectives: To measure total serum IgE levels in cases (n=127, males=45) and controls (n=142, Males=64), specific IgEs in cases (n=90, Males=53), and controls (n=82, Males=38). Materials and Methods: Cases reported wheeze and/or use of asthma medications in the last 12 months, while controls answered negatively to both and rhinitis. Results: Total Serum IgE (n=269) was raised (>144 IU/l) in 70/127 cases vs 25/142 controls (p=.0001). In males 30/76 of cases vs 11/64 controls (p=.005), while in females cases 15/51 vs 14/78, (p=.14). Positive specific IgE (>0.34 U/ml) was noted for at least one allergen in 54/90 cases vs 30/82 controls (p=.002). House dust mite (HDM) was positive in 27/90 cases vs 12/82 controls (p=.0001), Parietaria positive 12/90 cases vs 2/82 controls (p=.011), cat 22/90 vs 13/82 controls (p=.19), while in male subgroup 14/53 of cases were positive vs 4/38 controls (p=.06). Dog 9/90 cases vs 8/82 controls (NS). Olive positive in 13/90 cases vs 8/82 controls (NS). Alternaria positive in 6/90 cases vs 2/82 controls (NS). Goldenrod Solidago Virgaurea positive in 2/90 cases vs 1/82 controls, and Cladosporium 0/90 cases, 1/82 controls. Conclusion: Positive Total serum IgE and specific IgE to HDM and Parietaria in all patients and cat in males only were higher in cases than in controls.peer-reviewe

Association between the concentration and the elemental composition of outdoor PM2. 5 and respiratory diseases in schoolchildren : a multicenter study in the Mediterranean area

Asthma is a worldwide health problem and its prevalence has been increasing in many countries, especially in young children [1]. Asthma prevalence is particularly high in industrialized countries, even though a change in trend was noticed in the most recent years [2]. Multiple genetic factors increase the risk of developing asthma, whilst environmental conditions play a fundamental role in the expression of its symptoms [3]. In fact, the avoidance of air pollution has been suggested as a nonpharmacological intervention for the prevention of asthma exacerbations in the latest Global Initiative for Asthma (GINA) Guidelines [1]. Exposure to outdoor air pollution increases asthma symptoms, and asthmatic children are at increased risk of adverse effects from poor air quality [4,5]. The World Health Organization (WHO) stated that a high level of outdoor pollutant concentration is a determinant of worsening asthma symptoms in both children and adults [6]. In particular, high airborne particulate matter (PM) concentration has been associated with worsening of symptoms, especially in sensitive children [7], and the prevalence of allergic respiratory diseases is higher in urban areas and still on the rise [8]. Children vulnerability to atmospheric pollution was attributed to their high breath rate and to both physiological and anatomical immaturity [9]. A number of studies have demonstrated an association between respiratory symptoms, the diagnosis of asthma, and proximity of residences to industrial settlements such as oil refineries, petrochemical plants [10–12], and power plants [13,14]. Thus, living in urban environments or in proximity to industrial complexes may worsen respiratory health in children. The aim of the study was to assess the potential role of residing in different areas which had varying levels of pollution on current allergic respiratory diseases in schoolchildren. Thus, by means of a multicenter cross-sectional study, we evaluated children living in areas close to petrochemical and power plants in a southern Mediterranean area, comparing them with those living in rural and urban areas of Sicily and Malta. We used a modified ISAAC (International Study of Asthma and Allergies in Childhood) questionnaire to collect data on individual characteristics and respiratory and allergic symptoms. We also evaluated children exposure to a set of elements measured in outdoor PM with aerodynamic diameter <2.5 µm (PM2.5) through a semi-ecological approach.peer-reviewe

Comparison of aeroallergen sensitisation patterns in the United States and Europe

The global prevalence of allergic diseases have increased considerably and are a major socio-economic burden. Asthma is a complex disease and understanding asthma phenotypes and endotypes could eventually lead to individualised management, and offer better symptom control and quality of life. In this review, we first summarise the pathogenesis of atopic asthma and delve into the assessment of sensitisation to aeroallergens through skin prick testing and serological testing with total and specific immunoglobulin E testing. We will then analyse the distribution of aeroallergen sensitisation patterns in the United States and Europe and its effect on the population. This review gives a comprehensive overview on atopy and it compares the prevalence and effect of atopy within various regions of both continents using data from large multicentre studies. We will conclude this review by discussing the efficacy of add-on treatments in the most prevalent severe asthma phenotypes and endotypes.peer-reviewe

Indoor air quality in schools of a highly polluted south Mediterranean area

This study aimed at surveying lower secondary schools in southern Italy, in a highly polluted area. A community close to an industrial area and three villages in rural areas was investigated. Indoor temperature, relative humidity (RH), gaseous pollutants (CO 2 and NO 2 ), selected biological pollutants in indoor dust, and the indoor/outdoor mass concentration and elemental composition of PM 2.5 were ascertained. Temperature and RH were within, or close to, the comfort range, while CO 2 frequently exceeded the threshold of 1000&nbsp;ppm, indicating inadequate air exchange rate. In all the classrooms, median NO 2 levels were above the WHO threshold value. Dermatophagoides p. allergen concentration was below the sensitizing threshold, while high endotoxin levels were detected in the classrooms, suggesting schools may produce significant risks of endotoxin exposure. Concentration and solubility of PM 2.5 elements were used to identify the sources of indoor particles. Indoor concentration of most elements was higher than outdoors. Resuspension was responsible for the indoor increase in soil components. For elements from industrial emission (Cd, Co, Ni, Pb, Sb, Tl, V), the indoor concentration depended on penetration from the outside. For these elements, differences in rural vs industrial concentrations were found, suggesting industrial sources may influence indoor air quality nearby schools

The role of oral methotrexate as a steroid sparing agent in refractory eosinophilic asthma

The use of oral methotrexate for refractory eosinophilic asthma in a tertiary asthma referral centre, Glenfield Hospital, Leicester, was evaluated between January 2006 and December 2014. The patients ( n = 61) were carefully phenotyped at baseline with markers of airway inflammation. In addition, a structured oral methotrexate proforma was utilized to evaluate response to therapy and adverse events. Oral steroid withdrawal was attempted 3 months after commencing treatment. Several outcomes were evaluated at 12 months, including both efficacy and adverse effects; 15% ( n = 9/61) responded by achieving a decrease in daily oral corticosteroid dose (mean 8.43 (±8.76) mg), although we were unable to identify factors that predicted a treatment response. There were no other significant changes in any other clinical outcome measures. There was a high rate of adverse events (19/61 (31%)), primarily gastrointestinal/hepatitis. Our findings support the use of biological agents in preference to using oral methotrexate as a steroid sparing agent at the first instance. In the event of failure of these agents, oral methotrexate remains a therapeutic option, which can be considered in highly specialist severe asthma centres

Indoor air quality in schools of a highly polluted south Mediterranean area

This study aimed at surveying lower secondary schools in southern Italy, in a highly polluted area. A community close to an industrial area and three villages in rural areas was investigated. Indoor temperature, relative humidity (RH), gaseous pollutants (CO 2 and NO 2 ), selected biological pollutants in indoor dust, and the indoor/outdoor mass concentration and elemental composition of PM 2.5 were ascertained. Temperature and RH were within, or close to, the comfort range, while CO 2 frequently exceeded the threshold of 1000&nbsp;ppm, indicating inadequate air exchange rate. In all the classrooms, median NO 2 levels were above the WHO threshold value. Dermatophagoides p. allergen concentration was below the sensitizing threshold, while high endotoxin levels were detected in the classrooms, suggesting schools may produce significant risks of endotoxin exposure. Concentration and solubility of PM 2.5 elements were used to identify the sources of indoor particles. Indoor concentration of most elements was higher than outdoors. Resuspension was responsible for the indoor increase in soil components. For elements from industrial emission (Cd, Co, Ni, Pb, Sb, Tl, V), the indoor concentration depended on penetration from the outside. For these elements, differences in rural vs industrial concentrations were found, suggesting industrial sources may influence indoor air quality nearby schools