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Chronic cough is a debilitating condition affecting 10-12% of the general population and is one of the leading causes for referral to secondary care. Many conditions have been associated with chronic cough, including asthma, gastro-esophageal reflux disease and upper airways cough syndrome. Inflammatory airway conditions including cough variant asthma (CVA) and non-asthmatic eosinophilic bronchitis (NAEB) contribute to a significant proportion of presentations with chronic cough, with differing diagnostic criteria and different responses to commonly used asthma therapy for their respective diagnoses. Mechanistic studies in both animal models and humans have identified increased neuronal sensitivity and subsequent central sensitization. These mechanisms include inflammatory-mediated nociceptor sensitization and alterations of afferent nerve terminal excitability, phenotypic changes in the vagal afferent neurons over time, and central neuroplasticity resulting from increased synaptic signalling from peripheral afferents. The aim of this review is to discuss the mechanisms, neurophysiology, and management approaches currently available for patients presenting with chronic cough with underlying asthma, CVA, and NAEB and to shed a light on areas of further research required to elucidate the mechanisms of cough in this patient population.

Aims The role of dynamic changes in lactate concentrations on prognosis in acute heart failure has been poorly investigated. The aim of this study was to explore the predictive value of 24 h time‐weighted lactate (LACTW) in patients with acute heart failure. Methods and results Ninety‐six consecutive acute heart failure patients presenting to the Emergency Department of San Paolo Hospital, Naples, Italy, were prospectively enrolled. Arterial blood lactate was measured at admission and during the following 24 h at random time intervals. LACTW was obtained by the sum of the average lactate values among consecutive time points multiplied by the intervals between consecutive time points and dividing the sum by the total time (24 h). The outcome was a composite of need of admission to the intensive care unit, hospitalization duration >7 days, or intra‐hospital death. Admission lactate, maximum measured lactate, and LACTW were collected. Univariate and multivariate Cox regression analysis was applied to determine the hazard ratio (HR) of developing the outcome. Forty‐three patients experienced the pre‐specified outcome. In sex‐adjusted and age‐adjusted multivariable analysis, LACTW predicted the outcome occurrence (HR: 1.51, 95% confidence interval: 1.24, 1.84, P

BackgroundFrailty is a robust predictor of poor outcomes among patients with chronic obstructive pulmonary disease yet is not measured in routine practice. We determined barriers and facilitators to measuring frailty in a hospital setting, designed and implemented a frailty-focused education intervention, and measured accuracy of frailty screening before and after education.MethodsWe conducted a pilot cross-sectional mixed-methods study on an inpatient respiratory ward over 6 months. We recruited registered nurses (RNs) with experience using the Clinical Frailty Scale (CFS). RNs evaluated 10 clinical vignettes and assigned a frailty score using the CFS. A structured frailty-focused education intervention was delivered to small groups. RNs reassigned frailty scores to vignettes 1 week after education. Outcomes included barriers and facilitators to assessing frailty in hospital, and percent agreement of CFS scores between RNs and a gold standard (determined by geriatricians) before and after education.ResultsAmong 26 RNs, the median (IQR) duration of experience using the CFS was 1.5 (1–4) months. Barriers to assessing frailty included the lack of clinical directives to measure frailty and large acute workloads. Having collateral history from family members was the strongest perceived facilitator for frailty assessment. The median (IQR) percent agreement with the gold-standard frailty score across all cases was 55.8% (47.2%–60.6%) prior to the educational intervention, and 57.2% (44.1%–70.2%) afterwards. The largest increase in agreement occurred in the ‘mildly frail’ category, 65.4%–81% agreement.ConclusionsBarriers to assessing frailty in the hospital setting are external to the measurement tool itself. Accuracy of frailty assessment among acute care RNs was low, and frailty-focused rater training may improve accuracy. Subsequent work should focus on health system approaches to empower health providers to assess frailty, and on testing the effectiveness of frailty-focused education in large real-world settings.

Prevalence estimates and evidence informing treatment targets for thyroid dysfunction largely come from studies of middle-aged adults. We conducted a cross-sectional analysis to determine the prevalence of thyroid dysfunction and risk factors for abnormal thyroid tests in participants aged ≥65 in the Atherosclerosis Risk in Communities (ARIC) study (N = 5,392). We measured serum concentrations of triiodothyronine (T3), free thyroxine (FT4), thyroid peroxidase antibody (Anti-TPO), and thyroid stimulating hormone (TSH). In this population (58% women, 22% black), 17% reported medication use for thyroid dysfunction. Among those not on treatment, the prevalence of overt and subclinical hypothyroidism was 0.82% and 6.06%, respectively. Overt and subclinical hyperthyroidism affected 0.26% and 0.78%, respectively. Multivariable adjusted TSH, FT4 and T3 levels were 25%, 1.3% and 3.9% lower in blacks compared to whites, respectively. Men were less likely to be anti-TPO positive compared to women (p

Despite recent advances in Pulmonary Arterial Hypertension (PAH) treatment, this condition is still characterized by an extremely poor prognosis. In this review, we discuss the use of newly-approved drugs for PAH treatment with already known mechanisms of action (macitentan), innovative targets (riociguat and selexipag), and novel therapeutic approaches with initial up-front combination therapy. Secondly, we describe new potential signaling pathways and investigational drugs with promising role in the treatment of PAH.

Amidst the uncertainty of the current days, as we slowly recover from COVID-19?s first wave and apprehending its second, medical trainees from all different backgrounds should reflect back on how this pandemic has affected our medical training Many of which were halted as elective procedures and clinics were postponed indefinitely as a measure to contain the virus and focus all medical resources on battling the pandemic 1 However, albeit the negative consequences on our medical education, the COVID-19 emergency department will undeniably make us all better physicians

Introduction: The COVID-19 pandemic is rapidly evolving with the number of cases exponentially rising. The research scientific community has reacted promptly as evidenced by an outstanding number of COVID-19 related publications. As the number of scientific publications rapidly rises, there is a need to dissect the factors that lead to highly impactful publications. To that end, the present paper summarizes the characteristics of the top 50 cited COVID-19-related publications that emerged early during the pandemic. Methods: A systematic search of the Web of Science, Scopus, and Google Scholar was performed, using keywords related to COVID-19 and SARS-CoV-19. Two independent authors reviewed all the search results, screening for the top 50 cited COVID-19-related articles. Inclusion criteria comprised any publication on COVID-19 or the SARS-CoV-2 virus. Data extracted included the type of study, journal, number of citations, number of authors, country of publication, and study content. Results: As of May 29th, the top 50 cited articles were cited 63849 times during the last 4 months. On average, 14 authors contributed to each publication. Over half of the identified articles were published in only 3 journals. Furthermore, 42% and 26% of the identified articles were retrospective case series and correspondence/viewpoints, respectively, while only 1 article was a randomized controlled trial. In terms of content, almost half (48%) of the identified publications reported clinical/radiological findings while only 7 out of the 50 articles investigated potential treatments. Conclusion: By highlighting the characteristics of the top 50 cited COVID-19-related articles, the authors hope to disseminate information that could assist researchers to identify the important topics, study characteristics, and gaps in the literature.

Objective: To report a rare case of a male patient with primary hyperparathyroidism due to a parathyroid hormone (PTH)-secreting, intrathymic, cystic, parathyroid adenoma.Methods: The pertinent clinical features, laboratory data, radiologic and pathologic findings are reported, along with a brief literature review.Results: A 69-year-old male was followed for asymptomatic hypercalcemia secondary to primary hyperparathyroidism since 2013. He was also incidentally found to have an anterior mediastinal mass on a chest X-ray which remained stable on annual follow-up. He was monitored regularly with serial calcium and renal function tests, with no indication for surgical intervention. Dual-phase 99mTc-Sestamibi scan did not localize a culprit parathyroid gland in the neck or upper chest. He presented in 2015 with renal failure and hypovolemic shock secondary to severe hypercalcemia (calcium 17.20 mg/dL, PTH 3,452 pg/mL) requiring intensive care unit admission. Treatment with aggressive hydration, diuresis and pamidronate failed to lower calcium levels. Patient underwent emergent surgical exploration with combined resection of 2 enlarged, eutopic parathyroid glands suspicious for adenoma and the cystic mediastinal mass. PTH levels from fluid within the cystic mediastinal mass were elevated at 1,290,000 pg/mL. Immediate postoperative PTH and calcium levels dropped to 58 pg/mL and 10.80 mg/dL, respectively. Pathology of the mediastinal mass was consistent with ectopic, intrathymic, parathyroid adenoma.Conclusion: Anterior mediastinal mass in the setting of hypercalcemia should be considered as a possible source of ectopic PTH production in the setting of an otherwise negative 99mTc-Sestamibi parathyroid scan. Definitive treatment by resection of the mass is potentially curative.Abbreviations: PHPT primary hyperparathyroidism; PTH parathyroid hormone

Title: Assessing an Educational Intervention to Improve Recognition of Frailty in Hospitalized Patients with COPD Background: Frailty is common among COPD patients and is associated with poor health outcomes. There is a lack of data regarding the reliability of frailty assessments by frontline hospital staff. Objectives: 1. Design an educational intervention to improve the recognition of frailty among acute-care nurses. 2. Evaluate the inter-rater reliability of frailty assessments among nurses compared to a gold standard (GS). Methods: We conducted a mixed-methods study with 27 Registered Nurses (RNs) on a respiratory hospital ward. RNs evaluated 10 clinical vignettes and assigned a frailty score to each using the validated Clinical Frailty Scale (1=well to 8=terminally ill). A 1-hour frailty educational intervention was delivered to RNs. 1-week later the RNs assigned ratings to the same 10 vignettes. Fleiss Kappa were used to determine agreement between RN and GS ratings for each case. Results: For all scored cases, kappa measurements increased post-education compared to pre-education or remained stable in the case of frailty rating 3. No RN was able to identify vignettes with a GS frailty rating of 8 (Table 1). Conclusion: A 1-hour frailty educational intervention improved RNs ability to provide reliable frailty ratings among patients with COPD. Frailty rating of 8 was difficult to recognize among RNs.

Chronic obstructive pulmonary disease (COPD) is regarded as one of the leading causes of morbidity and mortality across the world, yet its proper diagnosis remains a challenge. Community-based population studies conducted in North and South America, Europe, Australia, and Asia have revealed that 10% to 12% of adults aged 40 years or older have evidence of persistent airflow limitation on spirometry, but only 20% to 30% of these subjects have been diagnosed with COPD. These studies collectively suggest that approximately 70% of COPD worldwide may be underdiagnosed. Conversely, other studies have shown that between 30% and 60% of patients with a previous physician diagnosis of COPD do not actually have the disease, and hence they have been overdiagnosed. In this review, we define under- and overdiagnosis and explore the prevalence and the burden of under- and overdiagnosis of COPD on both patients and healthcare systems. We further describe potential solutions to reduce the incidence of under- and overdiagnosis of COPD.

Context: Prevalence estimates and evidence informing treatment targets for thyroid dysfunction largely come from studies of middle-aged adults. There are limited data on the prevalence of thyroid dysfunction in older populations. Objective: To determine the prevalence of thyroid dysfunction and risk factors for abnormal thyroid tests in older adults. Methods: We conducted a cross-sectional analysis of data from participants aged 65 or older in the Atherosclerosis Risk in Communities (ARIC) study who attended visit 5 in 2011-2013. We measured serum concentrations of triiodothyronine (T3), free thyroxine (FT4), thyroid peroxidase antibody (Anti-TPO), and thyroid stimulating hormone (TSH) in 5,392 participants. We used multivariable linear and logistic regression to assess associations of demographic and clinical risk factors with thyroid hormone levels. Results: In this population of older adults (mean age 76; 56% women and 22% black), the prevalence of thyroid dysfunction was up to 25% when accounting for treated and untreated thyroid dysfunction categories. 15.6% reported use of medication for thyroid dysfunction. Among those not being treated, the prevalence of overt chemical hypothyroidism was 6.0% and subclinical hypothyroidism was 0.82%. Overt chemical hyperthyroidism and subclinical hyperthyroidism affected 0.26% and 0.78% of the population, respectively. Multivariable adjusted cardiovascular risk factor associations for TSH, FT4 and T3 levels are presented in Table . Men were less likely to be anti-TPO positive compared to women (OR=0.59, CI: 0.47,0.75, P Conclusions: There is a high prevalence of thyroid dysfunction in this older, community-based population. Prevalence of thyroid dysfunction and thyroid hormone levels vary with sex, race, age group and multiple cardiovascular risk factors. Accounting for these associations in the clinical setting might prove useful in improving thyroid function assessment in this age group.

Atrial arrhythmia (AA) occurrence in pulmonary arterial hypertension (PAH) may determine clinical deterioration and affect prognosis. In this study we assessed AA incidence in idiopathic (IPAH) and systemic sclerosis related PAH (SSc-PAH) and evaluated risk factors, management, and impact on mortality. We collected baseline data from consecutive IPAH or SSc-PAH patients prospectively enrolled in the Johns Hopkins Pulmonary Hypertension Registry between January 2000 and July 2016. During follow-up AA onset, treatment, and outcome were recorded. Among 317 patients (201 SSc-PAH, 116 IPAH), 42 developed AA (19 atrial fibrillation, 10 flutter-fibrillation, 9 atrial flutter, and 4 atrial ectopic tachycardia) with a 13.2% cumulative incidence. Most events were associated with hospitalization (90.5%). Electrical or pharmacological cardioversion was attempted in most cases. Patients with AA had higher right atrial pressure, pulmonary wedge pressure ( P

Introduction: Systemic sclerosis related pulmonary arterial hypertension (SScPAH) is characterized by a worse prognosis in comparison to idiopathic pulmonary arterial hypertension (IPAH). The estimated mortality risk reported in the current European guidelines for pulmonary hypertension has been evaluated mostly in IPAH patients. The aim of this study was to explore the ability of the risk assessment proposed in the guidelines to predict long-term mortality in SScPAH patients. Methods: The study population constituted patients diagnosed with SScPAH and prospectively enrolled in the Johns Hopkins Pulmonary Hypertension Program from 2000-2016. Patients with assessment of WHO functional class, 6-minute walking distance (6MWD), and right heart catheterization measurements at diagnosis were included in the analysis. A Cox proportional hazards model was used to examine the adjusted hazard ratio (HR) of mortality for each of the following four low-risk criteria: WHO functional class I-II, 6MWD >440m, right atrial pressure 2 . A Kaplan-Meier curve was plotted to describe overall survival at 5 years. Results: 151 patients (mean age 61.2, 84.8% female) were included in the analysis. Over a mean follow-up period of 4.9 years, 87 patients (57.6%) died. In Cox proportional hazards multivariate analysis, the HR (95%CI) of mortality compared to the presence of no low-risk criteria was 0.65 for one criterion (0.37-1.15), 0.34 for two (0.17-0.68), 0.16 for three (0.06-0.44), and 0.10 for four (0.01-0.78). Figure 1 describes the 5-year survival according to the number of criteria. Conclusion: Our study highlights that only a small proportion of SScPAH patients are diagnosed at an early stage of PAH disease, suggesting the need of more intense PAH screening programs for this population. Current guidelines for risk assessment in IPAH patients can also be helpful in SScPAH patients, particularly in identifying patients at higher risk of mortality.

Screening for PAH is significant in scleroderma as it may lead to early diagnosis and initiation of therapy http://ow.ly/TR6230aqRgq