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7.  A 29-year-old man with hospital-acquired cavitary pneumonia 
Mucormycosis is an infection that can manifest in many forms and is an emerging complication in several health care procedures. Portals of entry can be attributed to surgical procedures and medical devices such as chest tubes; however, the skin and gastrointestinal tract are the most common sites of infection and outbreaks have been traced to adhesive bandages, wooden tongue depressors and ostomy bags. This article describes the presentation, work-up, diagnosis and treatment of an East Asian immigrant who was admitted with acute hypoxemic respiratory failure.
Cavitary lung processes pose a formidable diagnostic challenge. Causes vary widely and include cavitary pneumonia, vasculitis and malignancy. In some cases, patient history and basic work-up may yield a diagnosis, but in others, an extensive work-up, including tissue biopsy, may be necessary to establish the cause. The authors present a case of cavitary pneumonia that complicated an open lung biopsy. It developed in the hospital and was caused by mucormycosis, a potential emerging infection causing health care-associated infections.
PMCID: PMC4173885  PMID: 24712011
Health care-associated; Mucormycosis
9.  Does prone positioning improve oxygenation and reduce mortality in patients with acute respiratory distress syndrome? 
The emergence of computed tomography imaging more than 25 years ago led to characterization of acute respiratory distress syndrome (ARDS) as areas of relatively normal lung parenchyma juxtaposed with areas of dense consolidation and atelectasis. Given that this heterogeneity is often dorsally distributed, investigators questioned whether care for ARDS patients in the prone position would lead to improved mortality outcomes. This clinical review discusses the physiological rationale and clinical evidence supporting prone positioning in treating ARDS, in addition to its complications and contraindications.
PMCID: PMC4173887  PMID: 24927376
10.  Do obstructive sleep apnea syndrome patients underestimate their daytime symptoms before continuous positive airway pressure treatment? 
The sleep fragmentation caused by obstructive sleep apnea (OSA) has several health-related consequences in addition to a reduced quality of life, the full impact of which are not realized by patients until they initiate therapy for OSA. Because OSA symptoms are not always overtly apparent, health care providers may not inquire about sleep history, which leads to delays in diagnosis and treatment. This study used scores derived from the Epworth Sleepiness Scale and the Quebec Sleep Questionnaire, two widely used instruments to assess hypersomnolescence, as an alternative to quality of life questionnaires to evaluate diurnal sleepiness.
BACKGROUND:
Daytime somnolence is an important feature of the obstructive sleep apnea (OSA) hypopnea syndrome and is usually subjectively assessed using the Epworth Sleepiness Scale (ESS).
OBJECTIVE:
To compare the scores of the ESS and different domains of the Quebec Sleep Questionnaire (QSQ) assessed before and after the first months of continuous positive airway pressure (CPAP) treatment, as well as retrospectively without treatment.
METHODS:
The ESS score and domain scores of the QSQ were obtained before and after a three-month period of CPAP treatment using a retrospective assessment of the pretreatment scores in 76 untreated OSA patients.
RESULTS:
Fifty-two patients completed the study. The ESS and QSQ scores significantly improved following CPAP therapy. Retrospective evaluation of the ESS score was significantly worse than pre- and post-treatment values (mean [± SD] pretreatment score 11.0±4.8; retrospective pretreatment score 13.5±5.1). Such differences were not observed in any domain of the QSQ, including the domain assessing hypersomnolence.
CONCLUSION:
OSA patients underestimated their sleepiness according to the most widely used instrument to assess hypersomnolence. This finding may not be observed with other methods used to assess OSA-related symptoms such as quality of life questionnaires.
PMCID: PMC4173888  PMID: 24712013
Daytime somnolence; Quality of life
11.  Similarities and differences between asthma health care professional and patient views regarding medication adherence 
Symptom control through daily adherence to controller medication is the cornerstone of asthma treatment. Although several common barriers to medication adherence have been identified in previous studies, patients’ perception of medication needs and actual intake has been less extensively examined. This study investigated the relationship among three groups of asthma stakeholders’ understanding of and barriers to medication adherence. The data obtained were also used to inform an intervention development process for a clinical trial designed to investigate a similar research question.
BACKGROUND:
The recent literature has reported disparate views between patients and health care professionals regarding the roles of various factors affecting medication adherence.
OBJECTIVE:
To examine the perspectives of asthma patients, physicians and allied health professionals regarding adherence to asthma medication.
METHODOLOGY:
A qualitative, multiple, collective case study design with six focus-group interviews including 38 participants (13 asthma patients, 13 pulmonologist physicians and 12 allied health professionals involved in treating asthma patients) was conducted.
RESULTS:
Patients, physicians and allied health professionals understood adherence to be an active process. In addition, all participants believed they had a role in treatment adherence, and agreed that the cost of medication was high and that access to the health care system was restricted. Major disagreements regarding patient-related barriers to medication adherence were identified among the groups. For example, all groups referred to side effects; however, while patients expressed their legitimate concerns, health care professionals believed that patients’ opinions of medication side effects were based on inadequate perceptions.
CONCLUSION:
Differences regarding medication adherence and barriers to adherence among the groups examined in the present study will provide insight into how disagreements may be translated to overcome barriers to optimal asthma adherence. Furthermore, when designing an intervention to enhance medication adherence, it is important to acknowledge that perceptual gaps exist and must be addressed.
PMCID: PMC4173889  PMID: 24712015
Adherence; Asthma; Focus groups; Medication
12.  Excessive daytime sleepiness among rural residents in Saskatchewan 
Obstructive sleep apnea and its sequelae are emerging public health issues in North America, and symptoms are often under-recognized or under-reported. Although several patient factors have been identified, limited data regarding the prevalence of and predictors for excessive daytime sleepiness in rural or remote populations area available. Accordingly, this study used Epworth Sleepiness Scale scores to evaluate daytime sleepiness in a large rural population participating in the Saskatchewan Rural Health Study.
BACKGROUND:
Obstructive sleep apnea (OSA) is a common diagnosis in clinical practice. Excessive daytime sleepiness may be a warning for possible OSA.
OBJECTIVES:
To assess the prevalence of excessive daytime sleepiness as measured by the Epworth Sleepiness Scale (ESS) in a rural community population; potential risk factors for OSA were also assessed.
METHODS:
In 2010, a baseline respiratory health questionnaire within the Saskatchewan Rural Health Study was mailed to 11,982 households in Saskatchewan. A total of 7597 adults within the 4624 (42%) respondent households completed the ESS questionnaire. Participants were categorized according to normal or high (>10) ESS scores. Data obtained included respiratory symptoms, doctor-diagnosed sleep apnea, snoring, hypertension, smoking and demographics. Body mass index was calculated. Multivariable logistic regression analysis examined associations between high ESS scores and possible risk factors. Generalized estimating equations accounted for the two-tiered sampling procedure of the study design.
RESULTS:
The mean age of respondents was 55.0 years and 49.2% were male. The prevalence of ESS>10 and ‘doctor diagnosed’ OSA were 15.9% and 6.0%, respectively. Approximately 23% of respondents reported loud snoring and 30% had a body mass index >30 kg/m2. Of those with ‘doctor-diagnosed’ OSA, 37.7% reported ESS>10 (P<0.0001) and 47.7% reported loud snoring (P<0.0001). Risk of having an ESS>10 score increased with age, male sex, obesity, lower socioeconomic status, marriage, loud snoring and doctor-diagnosed sinus trouble.
CONCLUSIONS:
High levels of excessive daytime sleepiness in this particular rural population are common and men >55 years of age are at highest risk. Examination of reasons for residual sleepiness and snoring in persons with and without sleep apnea is warranted.
PMCID: PMC4173890  PMID: 24791255
Epworth Sleepiness Scale; Farm; Nonfarm; Obesity; Rural; Sleep apnea; Snoring; Socioeconomic
13.  Higher effective oronasal versus nasal continuous positive airway pressure in obstructive sleep apnea: Effect of mandibular stabilization 
Continuous positive airway pressure (CPAP) is the most common treatment modality for individuals with obstructive sleep apnea. However, for a subset of patients, the efficacy of oronasal CPAP is diminished by posterior displacement of the mandible by oronasal masks. This study investigated whether the use of a mandibular advancement device could enhance the effectiveness of CPAP delivered by oronasal mask. In addition, the authors investigated cephalometric features that may be associated with poor response to oronasal CPAP.
BACKGROUND:
In some individuals with obstructive sleep apnea (OSA), oronasal continuous positive airway pressure (CPAP) leads to poorer OSA correction than nasal CPAP. The authors hypothesized that this results from posterior mandibular displacement caused by the oronasal mask.
OBJECTIVE:
To test this hypothesis using a mandibular advancement device (MAD) for mandibular stabilization.
METHODS:
Subjects whose OSA was not adequately corrected by oronasal CPAP at pressures for which nasal CPAP was effective were identified. These subjects underwent polysomnography (PSG) CPAP titration with each nasal and oronasal mask consecutively, with esophageal pressure and leak monitoring, to obtain the effective pressure (Peff) of CPAP for correcting obstructive events with each mask (maximum 20 cmH2O). PSG titration was repeated using a MAD in the neutral position. Cephalometry was performed.
RESULTS:
Six subjects with mean (± SD) nasal Peff 10.4±3.0 cmH2O were studied. Oronasal Peff was greater than nasal Peff in all subjects, with obstructive events persisting at 20 cmH2O by oronasal mask in four cases. This was not due to excessive leak. With the MAD, oronasal Peff was reduced in three subjects, and Peff <20 cmH2O could be obtained in two of the four subjects with Peff >20 cmH2O by oronasal mask alone. Subjects’ cephalometric variables were similar to published norms.
CONCLUSION:
In subjects with OSA with higher oronasal than nasal Peff, this is partially explained by posterior mandibular displacement caused by the oronasal mask. Combination treatment with oronasal mask and MAD may be useful in some individuals if a nasal mask is not tolerated.
PMCID: PMC4173891  PMID: 24791252
Continuous positive airway pressure; CPAP mask; Mandibular advancement device; Obstructive sleep apnea
14.  Management of necrotizing pneumonia and pulmonary gangrene: A case series and review of the literature 
Although rare, necrotizing pneumonia is a severe complication of bacterial pneumonia and is associated with a high morbidity and mortality. Given its rarity and the presence of only a few case reports and small retrospective cohort studies in the literature, there are no guidelines to direct the care of patients. This case series and literature review describes several presentations of necrotizing pneumonia and discusses pathophysiology, management recommendations and surgical options.
BACKGROUND:
Necrotizing pneumonia is an uncommon but severe complication of bacterial pneumonia, associated with high morbidity and mortality. The availability of current data regarding the management of necrotizing pneumonia is limited to case reports and small retrospective observational cohort studies. Consequently, appropriate management for these patients remains unclear.
OBJECTIVE:
To describe five cases and review the available literature to help guide management of necrotizing pneumonia.
METHODS:
Cases involving five adults with respiratory failure due to necrotizing pneumonia admitted to a tertiary care centre and infected with Streptococcus pneumoniae (n=3), Klebsiella pneumoniae (n=1) and methicillin-resistant Staphylococcus aureus (n=1) were reviewed. All available literature was reviewed and encompassed case reports and retrospective reviews dating from 1975 to the present.
RESULTS:
All five patients received aggressive medical management and consultation by thoracic surgery. Three patients underwent surgical procedures to debride necrotic lung parenchyma. Two of the five patients died in hospital.
CONCLUSIONS:
Necrotizing pneumonia often leads to pulmonary gangrene. Computed tomography of the thorax with contrast is recommended to evaluate the pulmonary vascular supply. Further study is necessary to determine whether surgical intervention, in the absence of pulmonary gangrene, results in better outcomes.
PMCID: PMC4173892  PMID: 24791253
Lung abscess; Lung resection; Necrotizing pneumonia; Pneumonia; Pulmonary gangrene
16.  Lobectomy in patients with cystic fibrosis 
Progressive lung disease is the primary contributor to morbidity and mortality in patients with cystic fibrosis. However, severe, localized refractory lung disease can develop in a subset of patients for whom surgical resection is the only treatment option. This study retrospectively reviewed and assessed the outcomes of lobectomy, particularly lung function and disease activity, in selected cystic fibrosis patients who failed standard therapies over a 15-year period.
BACKGROUND:
Some patients with cystic fibrosis (CF) develop severe but localized lung disease or recurrent hemoptysis/pneumothorax refractory to conventional medical therapies.
METHODS:
The outcomes of lung resection in patients with CF and worsening localized lung disease or recurrent hemoptysis/pneumothorax refractory to conventional therapy (n=15) were evaluated by reviewing the medical records of all patients with CF followed at the CF Center at Nationwide Children’s Hospital (Columbus, Ohio, USA), who underwent lobectomy over a 15-year period (1998 to 2012).
RESULTS:
The median age of the 15 patients (93% Caucasian) was 20 years (range two to 41 years) and their mean forced expiratory volume in 1 s (FEV1) was 59.5% of predicted one year before surgery. Three patients died within two years after lobectomy; all three deaths occurred in patients with an FEV1 ≤40% of predicted before surgery. There were no significant changes in mean height, weight, body mass index, hospital admissions or antibiotic use over time. The mean FEV1 decreased over time. Compared with at surgery, decline in FEV1 in the year before surgery was −5.4% (P=0.024) and decline in the year after surgery was −1.3% (P=0.513); however, the difference in the rate of decline was not statistically significant.
CONCLUSION:
In patients with CF and localized worsening bronchiectasis and/or recurrent hemoptysis/pneumothorax, lobectomy carried a significant risk of mortality, especially in patients with FEV1 ≤40% of predicted, and should only be considered when all other measures fail.
PMCID: PMC4173894  PMID: 24524113
Cystic fibrosis; Lobectomy; Pulmonary function tests
22.  The respiratory presentation of severe combined immunodeficiency in two Mennonite children at a tertiary centre highlighting the importance of recognizing this pediatric emergency 
Severe combined immunodeficiency (SCID) is considered to be a pediatric emergency, with respiratory distress being the most common presenting symptom. The authors present two cases of SCID in children <4 months of age with respiratory distress at a tertiary care centre due to a recently described homozygous CD3 delta mutation found only in the Mexican Mennonite population. Failure to respond to broad-spectrum antibiotics prompted investigation for possible SCID. Bronchial alveolar lavage fluid from both patients grew Pneumocystis jiroveci, and flow cytometry revealed absent T cells. The CD3 delta gene is believed to be important in T cell differentiation and maturation. The present article reminds pediatricians and pediatric respirologists that the key to diagnosing SCID is to have a high index of suspicion if there is poor response to conventional therapies.
PMCID: PMC3938231  PMID: 24288697
CD3 delta; Infant; Mennonite; Respiratory distress; Severe combined immunodeficiency (SCID)
23.  Granulomatous lymphocytic interstitial lung disease in infancy 
The authors report a case involving a child with chronic respiratory symptoms, who did not respond to conventional treatment. Low serum immunoglobin levels and pathological findings on lung biopsy revealed an unusual diagnosis for his age group. A specific treatment led to clinical improvement.
PMCID: PMC3938232  PMID: 24288696
Child; Common variable immunodeficiency; Granulomatous lymphocytic interstitial lung disease; Hypogammaglobulinemia
24.  Diffuse pulmonary ossification as a rare cause of interstitial lung disease 
Diffuse pulmonary ossification (DPO) is a rare form of interstitial lung disease. The present article describes a case of DPO in an elderly man who presented with progressive dyspnea on exertion and an isolated reduction in diffusing capacity for carbon monoxide. DPO may occur as sequelae of mitral stenosis, left heart failure, idiopathic pulmonary fibrosis, recurrent aspiration pneumonia, solid organ transplant, adult respiratory distress syndrome or may arise idiopathically. In the absence of other findings of interstitial lung disease, a lung biopsy is unlikely to be helpful in the management of these patients.
PMCID: PMC3938233  PMID: 24046820
Computed tomography; Interstitial lung disease; Pulmonary ossification; Restrictive lung disease
25.  New insights into the pathophysiology of mild chronic obstructive pulmonary disease 
The classification of mild chronic obstructive pulmonary disease (COPD) requires a postbronchodilator forced expiratory volume in 1 s (FEV1) to forced vital capacity ratio <0.7 and an FEV1 ≥80% predicted. Given their relatively well-preserved spirometry, some have argued that respiratory symptoms in patients with mild COPD are unlikely to be related to pulmonary function abnormalities and that early detection of COPD is a ‘waste of resources’. Despite this viewpoint, there is emerging clinical and physiological evidence of peripheral airway dysfunction, diminished quality of life and reduced physical activity levels, and increased mortality, hospitalizations, dyspnea and exercise intolerance in patients with mild COPD compared with healthy controls. The purpose of the present focused review was to summarize recent research regarding the pathophysiology and treatment of mild COPD.
PMCID: PMC3938234  PMID: 24511568
Dyspnea; Exercise; GOLD I

Results 1-25 (636)