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In clinical practice, the presence of wheezing generally indicates an airway disease. In rare circumstances, adjacent mediastinal structures may compress the tracheobronchial tree leading to obstructive physiology. Compression of the tracheobronchial region by an enlarged pulmonary artery (PA) is exceedingly rare. We present here a case of pulmonary hypertension, where the enlarged PA resulted in obstructive lung physiology with a relevant review of the literature.

Pulmonary rehabilitation (PR) is part of the recommended management plan of pulmonary hypertension (PHTN) and is important to better quality of life and exercise tolerance. This study aimed at determining effectiveness of PR on exercise capacity. Retrospective chart analysis was conducted on patients referred to our PHTN clinic for PR. Patients who had PHTN diagnosed on right heart catheterization (defined by mean pulmonary artery pressure>25 mmHg) and completed a standardized 12-week PR program were considered for the study. Patients' baseline exercise tolerance was recorded as speed attainable on a treadmill and duration of exercise in minutes. Demographics, age, sex, and oxygen use were obtained from chart review. Eighteen PHTN patients (5 male, 13 female; mean age 67.7±11.6 years) were considered for the study (six World Health Organization [WHO] group 1 pulmonary arterial hypertension [33.33%], eight WHO group III PHTH [44.44%], two WHO group IV and two WHO V PHTN [11.11%]). Treadmill speed improved following rehabilitation (1.3 mph [interquartile range {IQR}, 1.0-1.8 mph] to 2.2 mph [IQR, 1.3-2.8 mph]; P

Idelalisib is a novel treatment option for patients with chronic lymphocytic leukemia. A rare, but, fatal complication of using Idelalsib is drug induced pneumonitis. This article presents a case of Idelalsib induced pneumonitis in a patient with chronic lymphocytic leukemia along with a brief discussion of management plan.

Forced vital capacity (FVC) and slow vital capacity (SVC) are non-invasive tests of respiratory function. Although FVC has been extensively studied and is used in most PFT (pulmonary function test) labs, SVC can also be used in clinical practice as it is a more comfortable and convenient test to perform. SVC-based diagnostic criteria can lead to earlier detection of obstructive lung disease. In contrast to FVC, SVC is less affected by respiratory muscle fatigue, airflow patency, expiratory muscle weakness and air leakage making it an appropriate test of respiratory function in patients of amyotrophic lateral sclerosis (ALS) and other neuromuscular disorders. As respiratory insufficiency is the major cause of mortality in ALS patients, regular SVC measurement provides the respiratory functional status, so that early treatment can be started which improves the survival and quality of life in these patients. The purpose of this article is to highlight the importance of considering SVC in clinical practice.

Pulmonary arterial hypertension (PAH) is a rare and devastating disease which is characterized by worsening dyspnea and exercise tolerance. These patients are often found to have concomitant, depression, anxiety and impaired health-related quality of life (HRQOL). The interrelationship of dyspnea, depression and HRQOL in these patients is not well studied. Retrospective analysis was performed on 46 PAH patients (mean age 51.73). Patients completed Medical Outcomes Study Short - Form 36 V2 (SF-36) to measure HRQOL, Modified Medical Research Council (mMRC) Dyspnea Scale and Zung Depression Scale (ZDS). Physical Health Composite Scores (PCS) and Mental Health Composite Scores (MCS) were derived from SF-36. Spearman’s correlation was computed to determine degree of correlation between pairs of scales. 46 patients (12 males, 34 females; median age 51.4 yr) with confirmed PAH were considered for the study of which 36 patients (9 males, 27 females, median age 50.1 yr), were eligible for further analysis. MMRC Dyspnea Scale Score was 1.0 (Q1 to Q3:1.0 to 2.0). Median MCS was 52.1 (Q1 to Q3:41.7 to 57.1) and PCS was 37.9 (Q1 to Q3: 30.7 to 49.6). There was a significant negative correlation between dyspnea and PCS (r =−0.660, P

Nivolumab is a recently approved medication that shows significant clinical activity for various types of malignancies such melanoma, renal cell carcinoma and non-small cell carcinoma. Pneumonitis is a rare, but, possibly fatal manifestation that still remains ambiguous. This article presents a case of nivolumab induced pneumonitis in a patient with melanoma and discusses management plans.

In heart failure (HF), longitudinal changes in ventricular ejection fraction are poorly studied. The authors' objective was to document the dynamic changes in systolic function of both ventricles during acute HF and after a 3-month follow-up period, and to identify factors associated with ventricular improvement. A limited access dataset from the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE) trial provided by The National Heart, Lung, and Blood Institute was analyzed. In patients admitted to the hospital with acute HF, both ventricles were evaluated by echocardiography on admission, at discharge, and at 3 months. From baseline to 3 months, left ventricular ejection fraction (LVEF) increased in 43.4% of patients, decreased in 23.9%, and remained unchanged in 32.7%. Similarly, right ventricular systolic function improved in 40.9%, deteriorated in 25.0%, and remained stable in 34.1%. Weight loss during index admission and cardiac index/cardiac output increase were the only factors associated with LVEF improvement from baseline to month 3. There was no difference between ischemic and nonischemic etiology. In acute HF, ischemic or nonischemic, systolic function of the ventricles improved during 3 months in about 40% of patients and remained unchanged or deteriorated in the rest. Weight loss and increase in cardiac index/output during hospitalization was associated with improvement in LVEF.

Caregiver's burden is a multidimensional phenomenon affecting care-givers physically, emotionally and socially. It is critical to examine the burden of caregivers, because of the complex responsibility they have with their partners. There are relatively few studies that have examined factors linked with psychological burden amongst caregivers of pulmonary arterial hypertension (PAH) patients. Hence, it is pertinent to develop a good understanding of these factors and develop appropriate management strategies, modified to assist PAH caregivers.

Rapunzel syndrome a rare presentation occurs predominantly in young women or girls with psychiatric or emotional disordersand consists of trichobezoarwith a tail extending at least to the jejunum with symptoms suggestive of obstruction. With less than40 cases reported in literature till date we report a case in a young female diagnosed clinico-radiologically and treated surgicallywith removal of an intact trichobezoar extending from stomach till the jejunum.

The Internet has evolved into a universal platform to communicate and share information. It has profoundly impacted the way in which we organize, work, and learn. This paper proposes and evaluates a unifying framework that utilizes two Internet technologies, Web-based pull technology and push technology, in supporting classroom-based learning. We developed two fully operational education support systems based on the framework for two different types of courses. One system supports courses requiring extensive interactions, both communication and transfer of data files, among the course instructor, individual students, and student teams working on group projects. The other system supports courses requiring moderate interactions. One hundred and eighty-one students in eight classes across three semesters used and evaluated these systems. The study found that the systems supported learning by providing critical course information, study material, and assignments conveniently, timely, and in usable formats. The systems were user friendly and increased student productivity. The students were satisfied with the systems and found the systems useful. In addition, the study found that the system support for highly interactive courses was better than that for less interactive courses on all dimensions of system support.

Introduction: Fatigue is a known symptom of advanced lung disease and impacts quality of life and psychological health. Many of these patients undergo pulmonary rehabilitation as part of their therapy. Understanding the effect of pulmonary rehabilitation on fatigue in these patients is important, as one may be able to design more focused rehabilitation programs. The aim of this study is to evaluate the effect of pulmonary rehabilitation on fatigue as measured by the Fatigue Severity Scale (FSS) in patients with advanced lung disease. Material and Methods: Patients were enrolled in a standardized 6 week pulmonary rehabilitation program. They were asked to complete questionnaires to evaluate their self-reported fatigue (FSS), and depression as measured by Geriatric Depression Scale (GDS). The GDS is a self-reported assessment tool used to identify depression in patients. The FSS is a validated instrument that indicates a perception of fatigue that might require medical intervention. Participants completed questionnaires both at baseline and after completing the standardized pulmonary rehabilitation program. Data was analyzed in Statistical Analysis System (SAS). The change in FSS was evaluated using the Wilcoxon signed-rank test. p-values < 0.05 were considered statistically significant. Results: 21 patients (12 females; 9 males; mean age 64.3 ± 11.2 yrs) were considered for the study. Pre-pulmonary rehabilitation FSS scores ranged from 1.6 to 6.7 (mean score of 4.6 ± 1.7). Post pulmonary rehabilitation FSS scores ranged 1.0 to 6.2 (mean score of 3.9 ± 1.6). The median pre-rehabilitation FSS was 5.3 (inter quartile range; Q1–Q3: 3.0–6.1), and median post rehabilitation FSS was 3.9 (inter quartile range; Q1–Q3: 2.6–5.1). There was a significant decrease in FSS scores after completing pulmonary rehabilitation program (p < 0.0208). There was a decrease in GDS (pre-rehabilitation, mean: 5.5 ± 3.6; post-rehabilitation, mean: 4.2 ± 2.9), but this decrease was not statistically significant. The change in GDS correlated with the change in FSS (Spearman Correlation Coefficient 0.525, p < 0.0146). Conclusions: Patients with advanced lung disease reported a measurable component of fatigue. Participating in pulmonary rehabilitation resulted in significant improvement in patient’s self-reported fatigue severity. Further studies are necessary to evaluate and design interventions to improve fatigue in in the setting of advanced lung disease.

Decisional guidance is defined as how a decision support system (DSS) influences its users as they structure and execute the decision-making process. It is assumed that decisional guidance has profound effects on decision making, but these effects are understudied and empirically unproven. This paper describes an empirical, laboratory-experiment-based evaluation of the effectiveness of deliberate decisional guidance and its four types. We developed and used a comprehensive model consisting of four evaluation criteria: decision quality, user satisfaction, user learning, and decision-making efficiency. On these criteria, we compared decisional guidance versus no guidance, informative versus suggestive decisional guidance, and predefined versus dynamic decisional guidance. We found that deliberate decisional guidance was more effective on all four criteria; suggestive guidance was more effective in improving decision quality and user satisfaction, and informative guidance was more effective in user learning about the problem domain, whereas dynamic guidance was more effective than predefined guidance in improving decision quality and user learning; and both suggestive guidance and dynamic guidance reduced the decision time.

This paper describes several problems with the current Internet technologies and the way they are currently utilized in education and proposes an innovative solution. First, the paper discusses an activity matrix that maps learning activities involved in business education along two dimensions: level of monitoring and level of interaction. The paper then proposes a unifying framework that utilizes emerging Internet technologies to support these learning activities. The framework goes beyond a simple piece of software at the client level to provide a complete solution with the student client, the instructor client and the server level software. Furthermore, the paper describes the architecture, features and specific technologies used in an actual education support system developed from the framework.

The effectiveness of decision support systems (DSS) is enhanced through dynamic adaptation of support to the needs of the decision maker, to the problem, and to the decision context. We define this enhanced DSS as adaptive decision support systems (ADSS) and propose its architecture. In an ADSS, the decision maker controls the decision process. However, the system monitors the process to match support to the needs. The proposed architecture evolves from the traditional DSS models and includes an additional intelligent‘Adaptation’ component. The ‘Adaptation’ component workd with the data, model, and interface components to provide adaptive support. The architecture also integrates enhancements proposed in the past research. In this paper, we have illustrated the proposed architecture with two examples, a prototype system, and results from a preliminary empirical investigations

An academic course presents an opportunity for all participants to collaborate for improving their knowledge. This collective improvement of knowledge is typically documented via material provided by the instructor and notes and assignments prepared by students. Over the course of a semester, these materials provide not only the collective knowledge in that course, but also provide a chronological history of how the knowledge base evolved. The focus of this study is wiki collaboration in teaching & learning contexts. A wiki is a medium in which a group of individuals can work together asynchronously on an idea and easily capture the essence in a reusable format. Technically, a wiki is a collection of hyperlinked Web pages that are assembled with wiki software. With wikis, the line between reader and contributor is intentionally blurred. Further, wiki use reflects the view of an instructor as one who facilitates information sharing among learners rather than simply transmitting knowledge from themselves to their students. Our initial motivation to explore the usefulness of wikis for teaching and learning was driven by the fact that wikis provide a medium in which several individuals could asynchronously work together on an idea and easily capture the essence in a reusable format. We found that: (1) Wikis can be can be used for a variety of tasks ranging from business analyses to analyzing policy positions to serving as a signup sheet for students to self organize; (2) Instructor support and facilitation is key; and (3) Ease-of-use issues are present but do not preclude success.

Splenectomy predisposes patients to a slew of infectious and non-infectious complications including pulmonary vascular disease. Patients are at increased risk for venous thromboembolic events due to various mechanisms that may lead to chronic thromboembolic pulmonary hypertension (CTEPH). The development of CTEPH and pulmonary vasculopathy after splenectomy involves complex pathophysiologic mechanisms, some of which remain unclear. This review attempts congregate the current evidence behind our understanding about the etio-pathogenesis of pulmonary vascular disease related to splenectomy and highlight the controversies that surround its management.

Advanced lung diseases such as pulmonary arterial hypertension (PAH) and interstitial lung diseases (ILD) are chronic diseases that cause significantly high morbidity and mortality. As a result, patients can undergo some psychological changes leading to a poor quality of life and depression. Diagnosis of depression is often obscured because fatigue and apathy, two common symptoms of depression, frequently overlap with PAH and ILD. Healthcare providers are sometimes reluctant to ask or mistakenly believe that these symptoms are part of the ongoing disease process, rather than a serious condition like depression. Screening tools are available for physicians to be well positioned in recognizing clinical depression in PAH and ILD. A MedLine/PubMED search was performed identifying all relevant articles with “PAH”, “ILD”, “screening tools” and/or “Depression” in the title. The aim of this review is to provide a brief description of some of the instruments used to screen patients and classes of psychotropic medications accessible to physicians. While pulmonary rehabilitation programs can have a positive impact on patients, physicians should also utilize cognitive behavioral therapy (CBT) as part of regular care.

Pneumomediastinum (PM) is defined as the presence of free air in the mediastinal cavity. It is often regarded as a revealing sign of a more serious medical condition. PM is broken down into two categories, one, with an instigating event, referred to as secondary PM. The other is when free air is discovered in the mediastinal cavity without a clear etiology, referred to as spontaneous pneumomediastinum (SPM). Often misdiagnosed due to the vague nature of presenting symptoms, SPM must be part of the differential diagnosis of a chest pain patient to expedite discovery and if necessary, management. A MedLine/PubMED search was performed identifying all relevant articles with “SPM” in the title. Six case series were reviewed to determine what clinical scenario constitutes a possible case of SPM. Results showed that almost all patients with SPM exhibited some chest pain, but Hamman’s crunch was present in only one-fifth of patients. Patients with certain pre-existing pulmonary diseases showed a greater propensity for the presence of free air in the mediastinal cavity. SPM must be diagnosed and managed promptly due to rare, but serious complications and any chest pain with an unknown etiology should contain SPM in the differential diagnosis.