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Background: Epigenetic factors play an essential role in regulating the action of steroids in asthma. Steroids suppress inflammation by recruiting histone deacetylase-2 (HDAC-2), which removes the acetyl group of the nuclear factor kappa B-enabled inflammatory gene complex and disables its action. P-glycoprotein (P-gp)/Multidrug resistance-associated protein 1 (MRP-1), the energy-dependent efflux pumps, reduces the bioavailability of steroids in the cell by pumping it out. The expression of P-gp/MRP-1 and HDAC-2 has been linked to regulating the action of steroids in asthma. Therefore, the use of HDAC-2 inducer like theophylline might improve asthma control by improving steroid responsiveness. Objective: HDAC-2 inducer, theophylline, can improve glucocorticoid responsiveness in severe uncontrolled asthma (UA). Materials and Methods: We classified subjects into severe UA (n = 7, age: 52.36 ± 11.94 years), controlled asthma (CA) (n = 23, age: 50.65 ± 16.11 years), and treatment-naïve patients (n = 10, age: 50.60 ± 14.38 years). Peripheral blood mononuclear cells (PBMCs) were isolated and treated with theophylline (1 μM) and Trichostatin-A (TSA) (0.8 μM) for 48 h, for induction/suppression of HDAC-2, respectively. The messenger RNA (mRNA) expression extracted from PBMCs was studied for HDAC-2and P-gp/MRP-1 by quantitative real-time polymerase chain reaction. Results: The mRNA expression of P-gp/MRP-1 was higher, whereas HDAC-2 mRNA levels were significantly lower in UA at baseline. Exposure to theophylline reduced mRNA expression of P-gp/MRP-1 (fold change: 2.57/2.15 in UA; 1.27/1.26 in CA, respectively, P < 0.0001), but the HDAC-2 mRNA expression increased (fold change: 5.56 in UA; 6.85 in CA, respectively, P < 0.0001). However, TSA treatment resulted in higher mRNA levels for P-gp/MRP-1 (fold change: 7.45/7.26 in UA; 3.34/3.29 in CA, respectively, P < 0.0001), whereas it significantly lowered expression for HDAC-2(fold change: 1.39 in UA; 2.46 in CA, respectively, P < 0.0001). Conclusion: HDAC-2 inducer theophylline has a potential to induce response against steroid resistance in severe UA. [ABSTRACT FROM AUTHOR]

The renal transplant recipients are prone to the variety of infectious pathogens. The HRCT features could provide valuable information for differentiation diagnosis and treatment response. Findings in renal transplant recipients with manifestations of immune-compromised-related pulmonary diseases could be either pathogen-specific or -non-specific. It is particularly fundamental to recognize these imaging characteristics at suspicion of opportunistic infections in such patients. In this article, we present a review to refresh and update our knowledge of HRCT features of pulmonary infectious diseases in immune-compromised patients. [ABSTRACT FROM AUTHOR]

There are no large scale studies exclusive for pulmonary artery aneurysms as a cause of massive hemoptysis, only small studies are there. No randomised control trial is there to suggest efficacy of surgical excision or endovascular treatment over each other. It's well known that definite treatment by surgical excision carries high mortality when done in emergency sitting. Endovascular approach in such a patient is a less utilised treatment modality and that too with coil embolisation is not much practiced. This article emphasises the role of CTA in diagnosing and embolisation as emergency management of these aneurysms. [ABSTRACT FROM AUTHOR]

Background Pulmonary Renal Syndromes are heterogeneous group of disorders characterized by co-occurrence of rapidly progressive glomerulonephritis (RPGN) and alveolar hemorrhage due to an autoimmune etiology. This condition many a times presents as an emergency and can be rapidly fatal. A high index of suspicion is required to identify PRS early because appropriate diagnosis and timely institution of treatment is necessary for favorable results. The most common causes of PRS include anti-neutrophil cytoplasmic antibody (ANCA) associated vasculitis (AAV), anti-glomerular basement membrane (Anti-GBM) disease and systemic lupus erythematosus (SLE) which are responsible for almost 80% of the cases. All these condition share similar clinical presentation however there are some salient features which differentiate them in terms of prognosis and management. Methods This is a narrative review using the search terms; “pulmonary renal syndrome, granulomatosis with polyangiitis; eosinophilic granulomatosis with polyangiitis; microscopic polyangiitis; anti-GBM disease and systemic lupus erythematosus. Results The most common causes of PRS include anti-neutrophil cytoplasmic antibody (ANCA) associated vasculitis (AAV), anti-glomerular basement membrane (Anti-GBM) disease and systemic lupus erythematosus (SLE) which are responsible for almost 80% of the cases. All these condition share similar clinical presentation however there are some salient features which differentiate them in terms of prognosis and management. The response to immunosuppressive therapy and long term prognosis also differs because of distinguishing features in pathogenesis of these disorders. There is no consensus about the management protocols of pulmonary renal syndromes however, various immunological societies have laid down treatment protocols with variable success rates. Conclusion The syndrome of PRS has a high short-term mortality (20–40%). The rates of remission are >90% with current protocols and effective second line therapies exist for those who don't attain remission. Relapse rates are about 15% at 18 months and are higher with patients having PR3-ANCA and a diagnosis of GPA. A high index of suspicion is required to identify PRS early because treatment delays may be rapidly fatal. [ABSTRACT FROM AUTHOR]

Bronchoscopy is widely performed and generally considered safe. Cardiac complications during bronchoscopy are uncommon, and usually occur in elderly patients with coexistent coronary artery disease, hypertension, or severely impaired pulmonary function and resting hypoxemia. We report a patient who developed sudden onset restlessness, chest discomfort, hypotension, global ST elevation in multiple electrocardiogram leads, and acute severe left ventricular systolic dysfunction during a bronchoscopic transbronchial lymph node biopsy. Differential diagnosis included a massive myocardial infarction, apical ballooning (Tako-tsubo syndrome), or coronary vasospasm. The electrocardiogram changes resolved spontaneously, and a coronary angiogram 48 hours later revealed normal coronary artery anatomy and normal LV function. The patient made an uneventful recovery. It is important for physicians to be aware of such unusual complications to be able to appropriately manage these patients in clinical practice. [ABSTRACT FROM AUTHOR]

BACKGROUND: Noninvasive ventilation (NIV) is an emerging modality in the management of patients with acute respiratory failure. However, its role in severe acute asthma is not well defined. OBJECTIVE: Evaluate the efficacy of NIV in severe acute asthma. METHODS: Patients with severe acute asthma were randomized to receive either standard medical therapy or NIV in addition to medical therapy. The primary outcomes were improvement in forced expiratory volume in the first second (FEV1), intensive care unit (ICU) stay, and hospital stay. The secondary outcomes were rate of improvement in respiratory rate, blood pH, ratio of PaO2 to fraction of inspired oxygen (FIO2), PaCO2, requirement for inhaled medications, and failure of primary therapy. RESULTS: Fifty-three patients with severe acute asthma (42 females and 11 males, mean ± SD age 44 ± 15 y, FEV1 <30% of predicted) were randomized to NIV (n = 28) or standard medical therapy (n = 25, The baseline variables were similar in the 2 groups except for the mean duration of asthma, which was shorter in the standard-medical-therapy group. The median inspiratory and expiratory airway pressures applied were 12 cm H2O and 5 cm H2O, respectively. There was a significant improvement in respiratory rate, FEV1, and PaO2/FIO2 (but not pH or PaCO2) in both the groups, but no significant difference between the 2 groups. The number of patients who had a ≥ 50% improvement in FEV1 at 1, 2, and 4 hours was nonsignificantly greater in the NIV arm. ICU and hospital stay was significantly shorter in the NIV group. The mean dose of inhaled bronchodilator was significantly less in the NIV group. There were 4 instances of standard-medical-therapy failure, and all those patients improved with NIV. Two patients in the NIV arm required invasive ventilation. There was no mortality in either of the arms. CONCLUSION: In patients with severe acute asthma, the addition of NIV to standard medical therapy probably accelerates the improvement in lung function, decreases the inhaled bronchodilator requirement, and shortens the ICU and hospital stay, but a larger study is required to settle this issue. (Clinicaltrials.gov registration NCT00510991.) [ABSTRACT FROM AUTHOR]