Hemoptysis, a developing world perspective

BACKGROUND: Hemoptysis is a significant clinical presentation in respiratory medicine. Often a life threatening emergency, it mandates prompt assessment and intervention. Various investigations and management protocols are proposed globally, to advocate a standardized approach towards patients presenting with hemoptysis. It is the etiology, however, that has been known to influence clinical outcome and prognosis. With marked contrast in geographical patterns of pulmonary pathologies, etiological agents for hemoptysis vary over the world. Studies in West, usually demonstrate neoplastic and non-granulomatous causes to be the leading agents for hemoptysis. The diagnostic accuracy of various investigations and efficacy of management alternatives has been established there. Developing nations differ in their burden of diseases of lung. Lack of health resources and initiative often prevent quality research in critical areas. DESIGN: This is a retrospective observational study with a cross-sectional design in which charts of all patients admitted with the presentation of haemoptysis in the past ten years will be reviewed, at Aga Khan University Hospital, Karachi, Pakistan. A series of variables, based on previous literature on haemoptysis related to the objectives of present study, will be determined in the study. Demographics, co-morbids and etiology will be determined. Findings of various investigation modalities and their accuracy in localizing the bleeding site will be determined. Efficacy of different management strategies will also be observed. Also observed will be any complications and follow-up. DISCUSSION: Pakistan is a third world nation of over 150 million, established as highly endemic for pulmonary tuberculosis. To date no study has been generated to look into hemoptysis patterns, in this nation. Lack of evidence based medicine poses a major hindrance towards confident decision-making in the approach towards a patient presenting with hemoptysis in this country. This study is devised to obtain the first insight in this direction, from this part of the world. The etiologies, accuracy of various investigations and efficacy of treatment options will be investigated. The results and conclusions will prove to be of value not just for health administrators in this country, but many other regions that share similarities in patterns of pulmonary pathologies

Obstructive sleep apnea is underrecognized and underdiagnosed in patients undergoing bariatric surgery

The aim of this study was to evaluate prevalence of obstructive sleep apnea among patients undergoing bariatric surgery and the predictive value of various clinical parameters: body mass index (BMI), neck circumference (NC) and the Epworth Sleepiness Scale (ESS). We performed a prospective, multidisciplinary, single-center observational study including all patients on the waiting list for bariatric surgery between June 2009 and June 2010, irrespective of history or clinical findings. Patients visited our ENT outpatient clinic for patient history, ENT and general examination and underwent a full night polysomnography, unless performed previously. As much as 69.9% of the patients fulfilled the criteria for OSA (mean BMI 44.2 ± SD 6.4 kg/m2); 40.4% of the patients met the criteria for severe OSA. The regression models found BMI to be the best clinical predictor, while the ROC curve found the NC to be the most accurate predictor of the presence of OSA. The discrepancy of the results and the poor statistical power suggest that all three clinical parameters are inadequate predictors of OSA. In conclusion, in this large patient series, 69.9% of patients undergoing BS meet the criteria for OSA. More than 40% of these patients have severe OSA. A mere 13.3% of the patients were diagnosed with OSA before being placed on the waiting list for BS. On statistical analysis, increased neck circumference, BMI and the ESS were found to be insufficient predictors of the presence of OSA. Polysomnography is an essential component of the preoperative workup of patients undergoing BS. When OSA is found, specific perioperative measures are indicated

Head-and-neck paragangliomas are associated with sleep-related complaints, especially in the presence of carotid body tumors

Item does not contain fulltextOBJECTIVES: The carotid body functions as a chemoreceptor. We hypothesized that head-and-neck paragangliomas (HNP) may disturb the function of these peripheral chemoreceptors and play a role in sleep-disordered breathing. DESIGN: This is a case-control study. SETTING: This study was conducted in a tertiary referral center. PARTICIPANTS AND MAIN OUTCOME MEASURES: We assessed fatigue, sleep, and exercise capacity in 74 HNP patients using three questionnaires (Epworth Sleepiness Scale, St. George Respiratory Questionnaire, and a standard clinical sleep assessment questionnaire). Outcomes were compared to those of age- and sex-matched controls. RESULTS AND CONCLUSIONS: Activity, disturbance of psychosocial function, and total score were worse compared to controls (15.4 +/- 18.5 vs. 7.2 +/- 9.9, P = 0.007; 5.3 +/- 10.5 vs. 1.2 +/- 2.6, P = 0.008; and 10.4 +/- 12.9 vs. 5.0 +/- 4.8, P = 0.006, respectively). Patients reported more daytime fatigue, concentration difficulties, and depression (51% vs. 24%, P = 0.006; 31% vs. 10%, P = 0.010; and 19% vs. 2%, P = 0.012). Waking up was reported to be less refreshing in HNP patients (53% vs. 73%, P = 0.038). Dysphonia was a predictor of symptoms, activity, disturbance of psychosocial function, and total scores. Remarkably, the presence of a carotid body tumor was an independent predictor of increased daytime sleepiness (beta = 0.287, P = 0.029). In conclusion, patients with HNP have remarkable sleep-related complaints. Especially the presence of carotid body tumors appears to be associated with increased daytime somnolence.1 juni 201

Screening for small-cell lung cancer: A follow-up study of patients with Lambert-Eaton myasthenic syndrome

Purpose A small-cell lung carcinoma (SCLC) is found in 50% of patients with Lambert-Eaton myasthenic syndrome (LEMS). We evaluated screening to optimize screening strategy for SCLC. It is important to detect these tumors early in newly diagnosed patients with LEMS to offer optimal patient treatment. Patients and Methods A large nationwide cohort study of consecutive patients in the Netherlands, seen between 1990 and 2007, were screened for the presence of a tumor using chest x-ray, computed tomography of the thorax (CT-thorax), [F-18] fluorodeoxyglucose positron emission tomography (FDG-PET), bronchoscopy, and/ or mediastinoscopy. Results SCLC was found in 54 patients, and in 46 patients, no tumor was found during a median follow-up of 8 years (range, 3 to 26 years). All patients with SCLC had a positive smoking history and 86% were still smoking at diagnosis. SCLC was found in 92% of these patients within 3 months and in 96% within a year. At first screening, CT-thorax detected an SCLC in 45 patients (83%), whereas chest x-ray found the tumor in only 23 patients (51%). An SCLC was found during secondary screening in another nine patients (median, 3 months; range, 1 to 41 months). In six patients, a lung tumor was found by CT-thorax or FDG-PET, and in three patients, extrapulmonary metastases were found, initially without identifiable tumor mass on CT-thorax. Conclusion In almost all patients (96%), the SCLC was found within 1 year of diagnosis. CT-thorax scans detected most of the tumors (93%) and was far more sensitive than chest x-ray (51%). FDG-PET may have additive value in selected cases. We propose a screening protocol based on CT-thorax and FDG-PET