Austin Journal of Tropical Medicine & Hygiene is an open access, peer review journal publishing original research & review articles in all fields of Tropical Medicine & Hygiene. Tropical Medicine & Hygiene is a branch of medication that deals with health issues that arise unambiguously, or prove tough to manage in tropical and subtropic regions.
Austin Journal of Tropical Medicine & Hygiene is a comprehensive Open Access peer reviewed scientific Journal that covers multidisciplinary fields. We provide limitless access towards accessing our literature hub with colossal range of articles. The journal aims to publish high quality varied article types such as Research, Review, Short Communications, Case Reports, Perspectives (Editorials), Clinical Images.
Austin Journal of Tropical Medicine & Hygiene supports the scientific modernization and enrichment in Tropical Medicine & Hygiene research community by magnifying access to peer reviewed scientific literary works. Austin also brings universally peer reviewed member journals under one roof thereby promoting knowledge sharing, collaborative and promotion of multidisciplinary science.
Mark Haas Kidney Summary Banff 2013 in Brazil Kim Solez ,
Kidney summary from 12th Banff Conference on Transplant Pathology from the meeting in Comandatuba-Bahia, Brazil on August 23rd, 2013 http://cybernephrology.ualberta.ca/banff/2013
Présentation du Dr Dake lors du plus grand congrès de cardiologie interventionnelle.
Présentation faite en salle plénière devant plus de 800 personnes.
Austin Journal of Tropical Medicine & Hygiene is an open access, peer review journal publishing original research & review articles in all fields of Tropical Medicine & Hygiene. Tropical Medicine & Hygiene is a branch of medication that deals with health issues that arise unambiguously, or prove tough to manage in tropical and subtropic regions.
Austin Journal of Tropical Medicine & Hygiene is a comprehensive Open Access peer reviewed scientific Journal that covers multidisciplinary fields. We provide limitless access towards accessing our literature hub with colossal range of articles. The journal aims to publish high quality varied article types such as Research, Review, Short Communications, Case Reports, Perspectives (Editorials), Clinical Images.
Austin Journal of Tropical Medicine & Hygiene supports the scientific modernization and enrichment in Tropical Medicine & Hygiene research community by magnifying access to peer reviewed scientific literary works. Austin also brings universally peer reviewed member journals under one roof thereby promoting knowledge sharing, collaborative and promotion of multidisciplinary science.
Mark Haas Kidney Summary Banff 2013 in Brazil Kim Solez ,
Kidney summary from 12th Banff Conference on Transplant Pathology from the meeting in Comandatuba-Bahia, Brazil on August 23rd, 2013 http://cybernephrology.ualberta.ca/banff/2013
Présentation du Dr Dake lors du plus grand congrès de cardiologie interventionnelle.
Présentation faite en salle plénière devant plus de 800 personnes.
Cerebral Venous Sinus Thrombosis
Dr Rajiv Jha, MS
Senior Resident M Ch Neurosurgery
National Neurosurgical Referral Center
National Academy Of Medical Sciences
Bowel perforation in Dego’s disease: a lethal surgical scenario Ketan KETAN VAGHOLKAR
Malignant atrophic papulosis or Dego’s disease is a type of cutaneous disease with involvement of the gastrointestinal and central nervous system. Involvement of the gastrointestinal system by way of perforation invariably leads to a fatal outcome. Awareness of this condition will help in providing a high index of suspicion while managing unexplained multiple intestinal perforations or while dealing with rapidly developing complications in perforative peritonitis.
A Paradigm Shift in the Utilization of Therapeutic Plasmapheresis in Clinical...semualkaira
Therapeutic Plasma Exchange (TPE), frequently referred to as
plasmapheresis. is an automated procedure which separates whole
blood into plasma and blood cells. The plasma is discarded and
replaced with physiologic fluids and returned to the patient along
with the blood cells. Theoretically, any disease in which a humoral
phase is implicated in the pathogenesis may be at least partially
mitigated by removal of the patient’s plasma and replacement with
physiologic solutions. In clinical practice, TPE is used in a hospital
setting, usually as a last resort, to treat autoimmune diseases by removing circulating antibodies and/or immune complexes. Recently, it was demonstrated that TPE has several immunoregulatory
properties besides removal of circulating antibodies and immune
complexes. Both controlled and uncontrolled clinical studies have
demonstrated that TPE is associated with only a few mild adverse
reactions and can be performed safely in an outpatient setting.
We report our experience in treating patients with TPE on an outpatient basis with several different medical conditions (Alzheimer’s disease, Long Covid, PANDAS) and prophylactically in older
individuals for the attenuation of inflammaging
A Paradigm Shift in the Utilization of Therapeutic Plasmapheresis in Clinical...semualkaira
Therapeutic Plasma Exchange (TPE), frequently referred to as
plasmapheresis. is an automated procedure which separates whole
blood into plasma and blood cells. The plasma is discarded and
replaced with physiologic fluids and returned to the patient along
with the blood cells. Theoretically, any disease in which a humoral
phase is implicated in the pathogenesis may be at least partially
mitigated by removal of the patient’s plasma and replacement with
physiologic solutions
Objective: Diabetic nephropathy is one of the most serious complications of diabetes mellitus. It develops in approximately one-third of diabetic patients, years after the onset of metabolic abnormalities.
Study Design: The biopsy specimens were evaluated with the focus on light microscopy. The aim of our study was to reveal differences in the details and the frequency of occurrence of individual histomorphological changes in diabetic nephropathy and other glomerulonephritides.
Results: Diabetic nephropathy accounted for 14 out of 82 analyzed biopsies. Isolated thickening of the glomerular basement membrane was not present in any case, but along with some degree of mesangial expansion, hypercellularity or glomerulosclerosis was seen in 12 out of 14 findings of diabetic nephropathy. In other glomerular diseases, mesangial changes, but without glomerular basement membrane thickening, were the most frequent findings. In addition to glomerular lesions, some of the tubular, interstitial, and vascular changes were seen in 13 out of 14 patients with diabetic nephropathy. In other glomerulonephritides the combination of all these changes was a rare finding.
Conclusion: There are cases where immunofluorescence and electron microscopy cannot be performed or their results are not helpful. In such cases we must rely on light microscopic histomorphological changes.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
ABDOMINAL TRAUMA in pediatrics part one.drhasanrajab
Abdominal trauma in pediatrics refers to injuries or damage to the abdominal organs in children. It can occur due to various causes such as falls, motor vehicle accidents, sports-related injuries, and physical abuse. Children are more vulnerable to abdominal trauma due to their unique anatomical and physiological characteristics. Signs and symptoms include abdominal pain, tenderness, distension, vomiting, and signs of shock. Diagnosis involves physical examination, imaging studies, and laboratory tests. Management depends on the severity and may involve conservative treatment or surgical intervention. Prevention is crucial in reducing the incidence of abdominal trauma in children.
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
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1. International Pleural Newsletter
A Publication of the International Pleural Network
Volume 7 Issue 1
January 2009
Editors: Pleural Effusion in
Richard W. Light Nashville, TN, USA
Y.C. Gary Lee Oxford, UK Rheumatic Diseases
Guest Editor: Dr José M Porcel
Co-Editors:
Michael H. Baumann Jackson, MS, USA
Robert J.O. Davies Oxford, UK
Pleural Effusion Associated with
John E. Heffner Portland, OR, USA
Rheumatoid Arthritis
International Advisors:
P Astoul France D Bouros Greece Lone S Avnon MD
V C Broaddus USA T E Eaton New Zealand
A Ernst USA F V Gleeson UK
Mahmoud Abu-Shrakra MD
G Hillerdal Sweden S Idell USA Ben Gurion University of the Negev, Beer Sheva, Israel
Y Kalomenidis Greece T K Lim Singapore Mahmoud@bgu.ac.il
R Loddenkemper Germany S E Mutsaers Australia
M Noppen Belgium J M Porcel Spain Pleural disease is the most common thoracic
F Rodriguez-Panadero Spain S Romero Candeira Spain
S A Sahn USA G F Tassi Italy
manifestation in rheumatoid arthritis (RA). Pleural
L R Teixeira Brazil F S Vargas Brazil effusion was identified in 3.8% of asymptomatic RA
C Xie China A P C Yim Hong Kong patients using chest CT. In most cases it is small and
Administrator: Emma Hedley Oxford, UK without clinical significance1,2. Among patients with
emmahedley@orh.nhs.uk exudates, RA was the cause of pleural effusion in
0.6% of 2,346 patients and in 0.75% of 1,200 patients
The International Pleural Newsletter is distributed or who underwent thoracoscopy1,2. A literature review
web-posted by the: has identified 30 cases of pleural effusion in patients
with RA2. The data in this article are based on those
American College of Chest Physicians cases. Seventy percent were men with a mean age of
Asian Pacific Society of Respirology
56.2 years (range: 32-73)2. The effusion was
Asociación Latino Americana del Tórax
Belgian Society of Pulmonology diagnosed subsequent to RA in 16 and concurrently
Brazilian Thoracic Society in 14 patients. The mean interval (SD) between the
British Thoracic Society diagnosis of RA and pleural effusion was 1310.1
Costa Rican Thoracic Society years. In 7 patients the diagnosis of pleural effusion
European Respiratory Society came shortly before that of RA2.
International Mesothelioma Interest Group The most common pleural effusion-related
Italian Association of Hospital Pulmonologists symptoms are chest pain, shortness of breath and/or
Singapore Thoracic Society coughing. Patients may also present with fever and
South African Thoracic Society
weight loss and rarely respiratory distress, cardiac
Thoracic Society of Australia & New Zealand
Turkish Thoracic Society tamponade and hemodynamic instability. In most
cases, the arthritis was active at the time of diagnosis
The Newsletter is on line: of pleural effusion. Rheumatoid factor was found in
www.musc.edu/pleuralnews
1
2. more than 95% of patients and 20% presented with is rarely indicated. The pleural effusion resolves after
accelerated rheumatoid nodulosis1-3. an average of 14 months (range 1-36).
The characteristic findings of the RA-associated
pleural effusions are a very low pH in the range of Table 1. Causes of pleural effusions in RA patients based on the
6.4-7.14 in 70% of the patients and a glucose content results of thoracentesis
of <20 mg/dL in 80%1-4. The low glucose content is pH Glucose Predominant Differential diagnosis other
the result of consumption by the activated (mg/dL) cell than RA
<7.20 <20 Neutrophil Empyema
inflammatory cells and a metabolic block preventing <7.20 <20 Lymphocyte TB, malignancy
transfer of glucose into the pleural fluid. Low pH <7.20 <20 Eosinophil Drug reaction, methotrexate
correlated to low glucose levels. The effusions were Normal Normal Lymphocyte TB, malignancy, drug reaction
exudates with a mean level of LDH of 2,348 IU/ml Acknowledgments: Dr N Sion-Vardy kindly provided Figures.
and a mean total protein of 5.24 mg/dL. The cell
count in the effusions was >3,000 WBC/µL in 67% 1. Balbir-Gurman A, et al. Semin Arthritis Rheum 2006; 35:368-
of samples. The differential cell count was found to 78.
be of lymphocytic predominance in 37%, neutrophilic 2. Avnon LS, et al. Rheumatol Int 2007; 27:919-25.
3. Pettersson T, et al. Thorax 1982; 37:354-61.
in 56% and eosinophilic in 7% of samples. There 4. Faurschou P, et al. Thorax 1985; 40:371-5.
were no mesothelial cells2. In two cases, the 5. Naylor B. Acta Cytol 1990; 34:465-73.
differential cell count changed from neutrophilic to
lymphocytic predominance2 at a repeated tap.
The presence of
slender, elongated
tadpole cells on a Prevalence and Outcome of Lupus-
background of many Associated Pleural Effusions
cells, some of which are
decaying, on the Chi Chiu Mok MD FRCP
cytology smears, is Tuen Mun and Pok Oi Hospital, Hong Kong SAR, China
considered to be ccmok2005@yahoo.com
pathognomic3-5 (left).
Systemic lupus erythematosus (SLE) is a chronic
Thoracoscopic examination of the parietal pleura
inflammatory autoimmune disease that may affect
shows a "gritty" or frozen appearance, a slightly
any system of the body. Involvement of the serous
inflamed and thickened surface with small vesicles
membranes is one of the diagnostic criteria in the
and granules of about 0.5 mm3. On the microscopic
American College of Rheumatology classification.
examination the mesothelial cells are being replaced
Serositis of the pleura, pericardium or peritoneum
by palisades of pseudo-stratified epithelioid cells of
may lead to pain, fluid accumulation, adhesion and/or
macrophage origin, representing an erupted
fibrosis.
rheumatoid nodule (below). Calretinin staining may
The prevalence of lupus-related pleuritis/pleural
verify a lack of mesothelial
effusion varies widely depending on the clinical
cells. These patterns may not
criteria used, patient sampling, diagnostic methods,
be present on smaller, closed
and whether screening investigations were performed
pleural biopsies4.
and secondary causes of pleural effusion were
The differential diagnosis
included for analysis. In a study of 520 SLE patients
of pleural effusion among
conducted in the 1960s, the cumulative incidence of
patients with RA is outlined in
recurrent pleuritic pain was 45% and that of pleural
Table 1. The presence of the
effusion was 30%1. Pleurisy and pleural effusions
pathognomic cells precludes
were the initial manifestation of SLE in 3% and 1%
further investigations and invasive procedures.
of patients, respectively. Other studies also
Treatment modalities include systemic steroids, intra-
documented a high prevalence of pleuritic chest pain,
pleural steroids, methotrexate and/or other
with or without associated pleural effusion, in 41 to
immunosuppressive agents1-4. Surgical pleurectomy
56% of SLE patients during their disease course2,3.
2
3. Histologic evidence of pleuritis was present in up to intravenous immunoglobulins), or pleurodesis and
93% of SLE patients in an autopsy series, but this pleurectomy for symptomatic alleviation.
figure is likely to be a composite of all primary
1. Dubois EL, et al. JAMA 1964; 190:104-11.
(lupus-related) and secondary causes4. Pleural 2. Estes D, et al. Medicine (Baltimore) 1971; 50:85-95.
effusion in SLE is often small to moderate, but 3. Grigor R, et al. Ann Rheum Dis 1978; 37:121-8.
occasionally massive. Bilateral involvement is 4. Wang DY. Curr Opin Pulm Med 2002; 8:312-6.
present in about half the cases, which may be 5. Toya SP, et al. Semin Arthritis Rheum 2008 June 26.
associated with pericardial effusion and ascites. 6. Man BL, et al. Lupus 2005; 14:822-6.
Pleuritic chest pain has recently been recognized as a
common initial manifestation of the rare shrinking
lung syndrome in SLE5.
In a recent study, we showed that the point Shrinking Lung Syndrome in SLE
prevalence of symptomatic lupus-related serositis was
12% in 310 Chinese patients with a disease duration Sophie P Toya MD
of 7.2 years6. Among the 69 episodes of serositis, George E Tzelepis MD
44% were pleuritis/pleural effusion. Bilateral Athens University School of Medicine, Athens, Greece
effusions occurred in 36% of patients and the most gtzelep@med.uoa.gr
common presenting features were pleuritic chest pain,
Shrinking lung syndrome (SLS) is a rare
non-productive cough and dypsnea. However, the
complication of systemic lupus erythematosus (SLE)
prevalence of pleuritis in this study could have been
characterized by unexplained dyspnea, small lung
underestimated as surveillance investigations were
volumes, elevation of the diaphragm, and restrictive
not routinely performed.
physiology.
The exact pathogenesis of serositis in SLE remains
SLS may complicate SLE at any time over its
elusive. Histologic examination of the serosal
course, ranging from as early as a few months to 24
membranes reveals inflammation with infiltration by
years from disease onset1. Patients with SLS typically
lymphocytes, plasma cells and macrophages,
present with dyspnea, initially on exertion and later at
fibrinous exudates, and perivascular fibrinoid
rest; pleuritic chest pain is present in the majority of
necrosis4. Immune complexes, complement activation
patients1. On physical exam, patients with SLS may
products and immunoglobulins may also be found.
have shallow rapid breathing, use of accessory
However, these immune-mediated mechanisms may
muscles and, occasionally, paradoxical abdominal
not be specific to SLE. Persistent and unresolved
movements. Elevation of one or both
inflammation may result in serosal fibrosis and
hemidiaphragms is invariably present on chest
thickening.
radiographs. The volitional tests of diaphragmatic
Although lupus pleuritis often responds promptly
strength show that the maximal transdiaphragmatic
to treatment with non-steroidal anti-inflammatory
pressure is diminished, suggesting diaphragmatic
drugs or short courses of glucocorticoids, a small
dysfunction.
proportion of patients may present with life-
The pathophysiology of diaphragmatic
threatening effusion that is refractory to medical
dysfunction in SLS is unclear. The possibility of a
treatment.
myopathic process involving the diaphragm is not
In our study, 27% of patients with lupus-related
supported by the finding of normal diaphragmatic
pleural effusion required thoracentesis for
strength in response to magnetic stimulation of the
symptomatic relief6. Although all patients responded
phrenic nerve2.
to treatment within 2 months, 20% of patients had a
Could pleurisy account for the diaphragmatic
recurrence of pleuritis and 10% developed localized
dysfunction in SLS? Although it is too premature to
pleural fibrosis as a sequel. Patients with more
firmly attribute diaphragmatic dysfunction to
serious or recurrent/refractory pleural effusion may
pleurisy, indirect evidence suggests a possible
require more aggressive immunosuppressive
relationship. First, pleurisy is a prominent feature of
therapies (eg intravenous pulse methylprednisolone,
patients with SLS and a recent literature search found
cyclophosphamide, azathioprine, cyclosporin A,
that 65% of all reported SLS patients had pleuritic
3
4. chest pain at the time of diagnosis1. In addition,
typical SLS has also been reported in non-SLE
patients (e.g. rheumatoid arthritis) who similarly had IMAGES OF THE PLEURA
pleuritic chest pain and improved with anti-
inflammatory medications3. The occurrence of SLS in
non-SLE patients supports the hypothesis that the
association of diaphragmatic dysfunction in the SLS Pleural Lymphatics
is not unique to SLE but rather reflects the high Soraya Puente MD
prevalence of pleurisy in SLE. José M Porcel MD FCCP FACP
The mechanism by which pleurisy and its Arnau de Vilanova University Hospital, Lleida, Spain
associated pain may lead to diaphragmatic jporcelp@yahoo.es
dysfunction is probably through reflex inhibition of
diaphragmatic activation, in a manner similar to that The lymphatic systems of the visceral and parietal
described following abdominal or thoracic pleura hold roles in pleural fluid turnover. A
procedures. Although the exact neural pathways distinctive feature of the parietal pleura is the
involved are not entirely clear, experimental data presence of lymphatic stomata which open directly
suggest that inflammation of the parietal pleura may into the pleural space,
lead, through stimulation of the unmyelinated or thin representing the main
myelinated fibers belonging to the internal intercostal route of pleural fluid
nerves, to suppression of phrenic motor neuron absorption.
discharge4,5. An additional mechanism may also
involve the ‘phrenic-to-phrenic’ reflex. In animals, A normal human parietal
inflammation of the diaphragmatic pleura, through pleural membrane is
stimulation of phrenic nerve afferents, may inhibit shown using H&E stain
activation of the intercostal muscles, levator costae, (x200) (left) and Masson
as well as the diaphragm5,6. Given the high trichromic stain (x 200)
prevalence of pleurisy in SLE and the rarity of SLS, (below).
one would speculate that only pleurisy in a region
near the diaphragm or directly involving the Note the presence of
diaphragmatic pleura would be responsible for prominent large
diaphragmatic dysfunction. Anti-inflammatory lymphatic structures
therapy, the mainstay therapy for the SLS, is (L) in the subpleural
associated with symptom improvement in the connective tissue.
majority of patients1.
1. Toya SP, et al. Semin Arthritis Rheum. 2008 in press.
2. Hawkins P, et al. Thorax 2001; 56:329-30. This contrasts with
3. Ahmed S, et al. Arthritis Rheum 2001; 44:243-45. the appearance of
4. Jammes Y, et al. J Physiol 2005; 567:641-50. the visceral pleura
5. De Troyer A. J Physiol 1998; 508:919-27. (left; H&E x100).
6. Speck DF, et al. J Appl Physiol 1987; 62:941-45.
European School of Oncology education course
Approach to Pleural Cancer: State of the Art
7 - 8 May 2009: Athens, Greece.
For details, see www.eso.net
4
5. Treatment of Refractory Pleural that the parenteral form was withdrawn from the
market several years ago. Talc pleurodesis was
Effusion in SLE reported in six patients, either as a powder
Gideon Nesher MD (poudrage), or as a suspension in saline (slurry). Five
Maher Deeb MD had complete resolution of the fluid without
Gabriel S Breuer MD recurrences. Complications were observed in two
Shaare-Zedek Medical Center, Jerusalem, Israel patients: one developed empyema, and the other (who
nesherg@szmc.org.il underwent bilateral pleurodesis) developed a
restrictive defect.
Pleuritis-related pleural effusions in systemic lupus The main side effect of pleurodesis is pain, which
erythematosus (SLE) are usually small or moderate may last for a few days3. Rarely, debilitating pain
(400-1000mL); massive effusions are uncommon1. may last longer4. Mild fever may also be present for a
Treatment should be individualized: small few days. Lung function is not significantly affected
asymptomatic effusions may not require treatment; in most cases. However, there have been some reports
non-steroidal anti-inflammatory drugs are useful for of transient respiratory failure3,5, developing within a
mild pleurisy while corticosteroid therapy is indicated day of the procedure. Other uncommon complications
for more severe cases1. Most patients respond of talc pleurodesis include granuloma formation and
promptly. When the fluid volume is large and causing empyema. Finally, mechanical shunts, either pleuro-
shortness of breath, aspiration is necessary. Rarely peritoneal or pleuro-venous, may be appropriate for
are repeated thoracentesis or other local or systemic some non-malignant cases. However, data on the use
therapies required. of such procedures in refractory SLE-related
The following are data on massive refractory lupus effusions are limited6.
pleurisy from a review of the English-language In summary, refractory massive pleural effusion is
literature over the past 25 years2. Systemic therapy uncommon in SLE, but the affected patients pose a
included immunosuppressive drugs, plasmapheresis difficult management problem. Due to the small
and intravenous immunoglobulin. Immunosuppresive number of patients reported in the literature, it is
therapy with azathioprine, cyclophoshamide, difficult to determine the optimum intervention.
cyclosporine, methotrexate or hydroxychloroquine, in When refractory pleural effusion is part of an
addition to corticosteroids, generally did not prevent exacerbation of SLE, the treatment of choice would
fluid accumulation. Plasmapheresis was reported in be systemic. Local therapy should be employed if
one case, but it failed to achieve resolution of the systemic therapy fails, or in cases where pleural
effusion. Intravenous immunoglobulin (IVIG) effusion is the only manifestation of SLE. Talc
therapy was reported in two patients. In one case, the pleurodesis seems to be the preferred method of local
effusion recurred two months after the last dose. In therapy.
the other patient, IVIG therapy was followed by 4
months of treatment with cyclosporine and no fluid 1. D’Cruz D, et al. In: Wallace DJ, Hahn BH, eds. Dubois’
accumulation was observed during a two-year follow- Lupus Erythematosus, 7th ed, pp. 678-99. Philadelphia, 2007.
2. Breuer GS, et al. Semin Arthritis Rheum 2005, 34:744-9.
up.
3. de Campos JR, et al. Chest 2001; 119:801-6.
Local therapy included intra-pleural corticosteroid 4. Milton R, et al. Ann Thorac Surg 2003; 76:1740-1.
injections, pleurodesis with talc or tetracycline, and 5. Bondoc AY, et al. Cancer Invest 2003; 21:848-54.
pleurectomy. Intra-pleural corticosteroid injections 6. Artemiou O, et al. Ann Thorac Surg 2003; 76:231-3.
were reported in three SLE patients, with no
beneficial response whereas pleurectomy was
described in three other patients, with variable
responses. Regarding pleurodesis, the use of
tetracycline as a sclerosing agent was reported in four If you have any comment on the Newsletter or
patients: two of which had a favorable response, one interesting cases of pleural disease, contact:
had a transient response and pleurodesis failed in the Ms Emma Hedley emma.hedley@orh.nhs.uk
other one2. The primary problem with this agent is
5