Ambient Air Pollution and Dysanapsis: Associations with Lung Function and Chronic Obstructive Pulmonary Disease in the Canadian Cohort Obstructive Lung Disease Study.

Rationale: Outdoor air pollution is a potential risk factor for lower lung function and chronic obstructive pulmonary disease (COPD). Little is known about how airway abnormalities and lung growth might modify this relationship. Objectives: To evaluate the associations of ambient air pollution exposure with lung function and COPD and examine possible interactions with dysanapsis. Methods: We made use of cross-sectional postbronchodilator spirometry data from 1,452 individuals enrolled in the CanCOLD (Canadian Cohort Obstructive Lung Disease) study with linked ambient fine particulate matter (PM2.5) and nitrogen dioxide (NO2) air pollution estimates. Dysanapsis, or the ratio of the airway-to-lung volume calculated from thoracic computed tomography images, was used to examine possible interactions. Measurements and Main Results: In adjusted models, 101.7 ml (95% confidence interval [CI], -166.2 to -37.2) and 115.0 ml (95% CI, -196.5 to -33.4) lower FEV1 were demonstrated per increase of 2.4 ug/m3 PM2.5 and 9.2 ppb NO2, respectively. Interaction between air pollution and dysanapsis was not statistically significant when modeling the airway-to-lung ratio as a continuous variable. However, a 109.8 ml (95% CI, -209.0 to -10.5] lower FEV1 and an 87% (95% CI, 12% to 213%) higher odds of COPD were observed among individuals in the lowest, relative to highest, airway-to-lung ratio, per 2.4 µg/m3 increment of PM2.5. Conclusions: Ambient air pollution exposure was associated with lower lung function, even at relatively low concentrations. Individuals with dysanaptic lung growth might be particularly susceptible to inhaled ambient air pollutants, especially those at the extremes of dysanapsis.

Early rehabilitation reduces the likelihood of developing intensive care unit-acquired weakness: a systematic review and meta-analysis.

BACKGROUND: Intensive care unit-acquired weakness (ICUAW) is associated with significant impairments in body structure and function, activity limitation, and participation restriction. The etiology and management of ICUAW remain uncertain. OBJECTIVE: To estimate the extent to which early rehabilitation interventions (early mobilization [EM] and/or neuromuscular electrical stimulation [NMES]) compared to usual care reduce the incidence of ICUAW in critically ill patients. DATA SOURCES: We searched MEDLINE, EMBASE, CINAHL, Cochrane Central and Physiotherapy Evidence Database databases from inception to May 1st, 2017. ELIGIBILITY CRITERIA: Randomized controlled trials of EM and/or NMES interventions in critically ill adults. DATA EXTRACTION AND DATA SYNTHESIS: Data on the incidence of ICUAW and secondary outcomes were extracted. Both odds and risk ratios for ICUAW were pooled using the random-effects model. RESULTS: We identified 1421 reports after duplicate removal. Nine studies including 841 patients (419 intervention and 422 usual care) were included in the final analysis. The interventions involved EM in five trials, NMES in three trials, and both EM and NMES in one trial. Early rehabilitation decreased the likelihood of developing ICUAW: odds ratio of 0.63 (95% CI: 0.43 to 0.92) in the screened population, and 0.71 (95% CI: 0.53 to 0.95) in the randomized population. CONCLUSION, IMPLICATIONS OF KEY FINDINGS: Early rehabilitation was associated with a decreased likelihood of developing ICUAW. Our findings support early rehabilitation in the ICU. While results were consistent in both the screened and randomized populations, the wide confidence intervals suggest that well-conducted trials are needed to validate our findings. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO registration ID: CRD42017065031.

Predicting invasive fungal disease due to Candida species in non-neutropenic, critically ill, adult patients in United Kingdom critical care units.

BACKGROUND: Given the predominance of invasive fungal disease (IFD) amongst the non-immunocompromised adult critically ill population, the potential benefit of antifungal prophylaxis and the lack of generalisable tools to identify high risk patients, the aim of the current study was to describe the epidemiology of IFD in UK critical care units, and to develop and validate a clinical risk prediction tool to identify non-neutropenic, critically ill adult patients at high risk of IFD who would benefit from antifungal prophylaxis. METHODS: Data on risk factors for, and outcomes from, IFD were collected for consecutive admissions to adult, general critical care units in the UK participating in the Fungal Infection Risk Evaluation (FIRE) Study. Three risk prediction models were developed to model the risk of subsequent Candida IFD based on information available at three time points: admission to the critical care unit, at the end of 24 h and at the end of calendar day 3 of the critical care unit stay. The final model at each time point was evaluated in the three external validation samples. RESULTS: Between July 2009 and April 2011, 60,778 admissions from 96 critical care units were recruited. In total, 359 admissions (0.6 %) were admitted with, or developed, Candida IFD (66 % Candida albicans). At the rate of candidaemia of 3.3 per 1000 admissions, blood was the most common Candida IFD infection site. Of the initial 46 potential variables, the final admission model and the 24-h model both contained seven variables while the end of calendar day 3 model contained five variables. The end of calendar day 3 model performed the best with a c index of 0.709 in the full validation sample. CONCLUSIONS: Incidence of Candida IFD in UK critical care units in this study was consistent with reports from other European epidemiological studies, but lower than that suggested by previous hospital-wide surveillance in the UK during the 1990s. Risk modeling using classical statistical methods produced relatively simple risk models, and associated clinical decision rules, that provided acceptable discrimination for identifying patients at 'high risk' of Candida IFD. TRIAL REGISTRATION: The FIRE Study was reviewed and approved by the Bolton NHS Research Ethics Committee (reference: 08/H1009/85), the Scotland A Research Ethics Committee (reference: 09/MRE00/76) and the National Information Governance Board (approval number: PIAG 2-10(f)/2005).

The Role of Open Lung Biopsy in Critically Ill Patients with Hypoxic Respiratory Failure: A Retrospective Cohort Study.

Background. The aim of this study was to assess the utility of open lung biopsy in patients with hypoxic respiratory failure of unknown etiology admitted to an ICU and to examine the use of steroid therapy in this patient population. Methods. A retrospective cohort study was performed of all consecutive patients admitted to three tertiary care, university-affiliated, ICUs during the period from January 2000 to January 2012 with the principal diagnosis of hypoxic respiratory failure and who underwent an open lung biopsy. Results. Open lung biopsy resulted in a diagnostic yield of 68% and in a 67% change of management in patients. A multivariable analysis of clinical variables associated with acute hospital mortality demonstrated that postbiopsy systemic steroid therapy (OR 0.24, 95% C.I 0.06-0.96) was significantly associated with improved survival. Complications arising from the biopsy occurred in 30% of patients. Conclusion. Open lung biopsy had significant diagnostic yield and led to major changes in management and aided in end-of-life decision-making in the ICU. Systemic steroid therapy was associated with improved survival. The risk-benefit ratio of open lung biopsy is still unclear, especially given the availability of newer diagnostic tests and possible empirical therapy with steroids.

Histologic and morphometric study of human placenta in gestational diabetes mellitus.

AIMS: The aim was to study morphometry, site of umbilical cord insertion and histological changes in placentae of women with gestational diabetes mellitus and compare the results with those of normal pregnancies and observe the perinatal outcome. METHODS: It was an observational, correlational study of 130 placenta specimens collected from labour room and operation theatre of Department of Gynaecology & Obstetrics, Institute of Post Graduate Medical Education and Research, Kolkata. The subjects were mothers who attended antenatal clinic of the hospital regularly and delivered their babies in the same hospital. Cases were selected randomly, and divided in two groups: group A consisted of mothers having normal, uncomplicated pregnancy, group B consisted of mothers whose pregnancies were complicated by gestational diabetes mellitus. Morphometry, site of umbilical cord insertion and histological changes in placentae of all women were recorded. Perinatal outcome of the cases were also registered. The statistical methods used were chi-square test and Mann-Whitney U test. RESULTS: It was observed that the placentae of diabetic mothers were significantly bigger in size, weight, volume, area, thickness, diameter and circumference than those of normal mothers. Also, in diabetic mothers, there was significant increase in villous oedema, fibrin deposition, calcification and congestion of blood vessels. These placental changes were significantly correlated with birth weights of babies. Out of 70 mothers in Group B, 65 had live births, 5 had stillborn babies. CONCLUSIONS: Placentae of women with GDM showed several changes that may be associated with impaired functioning, leading to bad perinatal outcome.

Placental changes associated with maternal anaemia

The present study aimed to assess the morphological and histological changes of placentas associated with maternal anaemia (mothers with Hb level <11 g/dl). The study was conducted in Bankura Sammilani Medical College, West Bengal, India for a period of six months. Placentas collected from cases of maternal anaemia (Hb < 11 g/dl) were forty (40) and those collected from control mothers were thirty (30). All the deliveries were at full term (37-42 weeks) and in the antenatal periods were without any complications or diseases. Macroscopic and microscopic analyses of the placentas were done and these findings were compared. Statistical analysis was performed by using t-test for comparing the mean values of fetal weights, placental weights, placental indices and placental volumes of the maternal anaemia group with those of control group. It was observed that the mean fetal weight of pregnancy with anaemia group was less than those of the control group. The mean placental weight and mean placental volume in pregnancy with the anaemia group were more than the control group. Also, the mean placental index of the maternal anaemia group was higher than that of the control group. Light microscopy revealed increased fibrin deposition, increased syncytial knotting, more avascular villi with incomplete trophoblastic lining, stromal fibrosis, intervillous haemorrhage and cytotrophoblastic cell proliferation in placentas of anaemic mothers as compared to those of the controls. We concluded that maternal anaemia resulted into bigger, heavier placentas and smaller fetuses, whereas placental morphological changes showed signs of chronic hypoxia and placental insufficiency

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Drug utilization pattern in pregnant women in rural areas, India: cross-sectional observational study.

AIM: The aim of this study was to evaluate the drug-utilization trend of pregnant women in rural areas of central India. MATERIALS AND METHODS: This was a prospective, observational study using a questionnaire, face-to-face interview and a prescription audit. RESULTS: The majority of the subjects were primigravida (51.4%), from the lower socioeconomic group (71.3%) and with poor formal education. Although the drugs prescribed for them per prescription (2.66) were within rational limits, there was scope for improvement in generic (21%) and essential drugs (18%), antibiotics (9.6%) and injections (10.97%). CONCLUSIONS: Morbidity and mortality during the antenatal period occur due to different factors. Regular drug-utilization studies following the guidelines of the World Health Organization and information, education and communication factors related to drug use by pregnant women can be improved.

Drug use behaviour of pregnant women in rural India.

OBJECTIVE: To evaluate the drug use habit of pregnant women in villages of central India. METHODS: An observational, cross sectional study was conducted among six hundred fifty pregnant women from different randomly selected villages of Wardha district of central India through interviews on medicine use behaviour and evaluation of prescriptions. RESULTS: Pregnant women of younger age group from lower socio economic status constituted the majority of the study population. Major portion (97.7) of this socioeconomically backward population followed the doctor's advice as far as dose, frequency and duration of the drug was concerned. The antenatal mothers were of the opinion that, if the instructions on the drug envelop or foil was in written in the local language, it could be more helpful for them. CONCLUSION: Majority of the study population used drugs or medicines regularly but some mothers were reluctant. This indicated that even in this age of advancement of scientific knowledge, all antenatal mothers were not conversant with the advantages of drug use.

Surface area of chorionic villi of placentas: an index of intrauterine growth restriction of fetuses.

AIM: Histomorphometric studies of placentas from idiopathic intrauterine growth restricted (IUGR) fetuses as well as normal-weight (control) fetuses were performed to determine surface area of chorionic villi (mostly terminal and few intermediate) using stereological technique. The results were compared to determine the difference in the values of surface area of chorionic villi, and to establish any relationship between placental histomorphometric changes and IUGR. METHODS: Placentas from fifty (50) full-term, uncomplicated deliveries were collected; twenty eight (28) of them were associated with IUGR babies and twenty two (22) were from normal-weight babies. Placental weights and volumes were measured. Pieces of placental tissues were formalin-fixed, processed and embedded in paraffin. Seven-micron sections were cut and stained with HE stain. Histomorphometric and stereological studies were performed. RESULTS: IUGR placental weights and volumes were lower than those of controls. Surface areas of villi of IUGR placentas had a mean of 8.19 m(2) (SD +/- 2.88). For control placentas, the mean was 10.02 m(2) (SD +/- 1.83). The mean value of the surface area of villi of the IUGR group was significantly lower than that of the control group. CONCLUSION: These findings pointed to a defect in the normal interaction between trophoblast and maternal tissue, leading to a reduced surface area of villi. Because the surface area of the villi presents the interface between maternal and fetal circulation, its reduction might be the cause of idiopathic intrauterine growth restriction.

Gross morphological changes of placentas associated with intrauterine growth restriction of fetuses: a case control study.

The present study aimed to throw light to any gross morphological changes of placenta that might contribute to the development of idiopathic IUGR. Gross examination of placentas from full-term uncomplicated pregnancies delivering singleton live IUGR babies, and live normal-weight babies (controls) were performed; then the results were compared. Fifty full-term freshly delivered placentas were collected both from normal deliveries and C.S. Twenty-eight (28) placentas were associated with IUGR and twenty-two (22) were from controls. The positions of insertion of the umbilical cords, placental weights, volumes and diameters were noted. These gross examinations revealed that the control placentas were bigger in diameters, had usual positions of insertion of umbilical cords, mean placental weight was 416.77 gm and mean placental volume was 343.86 ml. In cases of IUGR placentas, there were some abnormal positions of insertion of umbilical cords in 11% placentas (marginal in 7.14% and velamentous in 3.57%), and placental weight and volume was significantly lower (p value<0.001). The placentas associated with IUGR were smaller in diameters than those of control group of placentas. The mean placental co-efficient of IUGR group in the present study was 0.156 (range 0.11-0.22) and that of the control group was 0.138 (range 0.12-0.18). The greater placental co-efficient in IUGR indicates that although both placentas and babies in IUGR had less weight, placental sizes were not relatively less. In fact, these placentas were functional, and even tried to compensate the abnormal morphology. Therefore, though IUGR fetuses were more frequently associated with morphologically abnormal placentas, it could not be conclusively decided whether this abnormal gross morphology actually contributed to the intrauterine growth restriction.

Ferritin, a potent threat for acute myocardial infarction?

BACKGROUND: Studies conducted have yielded contradicting results on the role of ferritin as a risk factor for acute myocardial infarction (AMI). The relation of ferritin status to risk of AMI in Indian men, along with other established major risk factors like serum total cholesterol, HDL cholesterol, LDL cholesterol, VLDL cholesterol and triglycerides has not been documented previously. The hypothesis that increased serum ferritin was related to increased chances of AMI along with the risk factors was tested. METHODS: Case control study involving 145 men (100 cases and 45 healthy control subjects) in the age group of 30-70 years. Serum ferritin levels were estimated by using ELISA, and other risk factors by enzymatic methods. RESULTS: Increased serum ferritin levels significantly (p < 0.001) correlated with an increase of other risk factors in Indian male patients with AMI. CONCLUSION: Significant direct correlation between serum ferritin levels and risk of AMI was observed.