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Context Cancer patients often experience cancer-related fatigue (CRF) and sleep disturbances due to cancer and cancer treatment, and symptoms can persist long after treatment. Despite these common occurrences, few studies simultaneously characterize CRF and sleep architecture among cancer patients. Objectives The objective was to characterize CRF and the sleep architecture of patients seen in a CRF clinic and sleep clinic at the University of Texas MD Anderson Cancer Center. Methods CRF Clinic medical records were retrospectively reviewed from September 1, 2006, to September 30, 2010, for self-reported performance status, fatigue, pain, sleep disturbance, depression, anxiety, and sleepiness (n = 219). Polysomnography results were recorded for those referred for additional sleep consultation (n = 39). Results Notably, patients often reported fatigue, sleep disturbance, excessive daytime sleepiness, and a majority of patients referred for a sleep consultation were diagnosed with obstructive sleep apnea (n = 33). Conclusion The results highlight the promise of an interdisciplinary collaboration between dedicated a CRF clinic and sleep clinic to conduct effective assessments to identify treatable CRF and sleep disorders.

Excessive daytime sleepiness (EDS) is commonly reported in patients with cancer, and it is also a cardinal feature of central disorders of hypersomnolence. Multiple sleep latency testing (MSLT) is used for objective assessment. A retrospective review of patients with cancer history who underwent formal sleep evaluation and MSLT from 2006 to 2019 was performed. Clinical characteristics, sleep-related history, and polysomnographic data were reviewed. Of 16 patients with cancer history, 9 were women (56%) and median age was 49. Cancer diagnoses included 4 central nervous system, 3 breast, 1 lymphoma, and 9 other solid malignancies, and 31% were undergoing active treatment. Comorbid conditions included depression, obstructive sleep apnea, and cancer-related fatigue. Daytime fatigue (94%), daily naps (81%), and EDS (69%) were the most common symptoms. Hypnopompic and hypnogogic hallucinations, sleep paralysis, sleep attacks, and cataplexy were present in a few. Epworth Sleepiness Scale scores were consistent with EDS in 88%, and mean sleep latency was less than 8 min in 69%. Only 31% had more than 2 sleep-onset REM periods. MSLT supported diagnoses of central disorders of hypersomnolence in 5 patients (4 narcolepsy, 1 idiopathic hypersomnia); 5 hypersomnia due to a medical disorder, psychiatric condition, or medication; and 6 with normal results. Pharmacotherapy was prescribed in 5 patients. EDS in patients with cancer may be multifactorial, but persistent symptoms may indicate an underlying disorder of hypersomnolence. Sleep referral and polysomnography to exclude other sleep disorders may be indicated. MSLT can help confirm the diagnosis. In those with normal MSLT, further evaluation for mood disorder should be considered.

Sleep and circadian rhythm disturbance are among the most commonly experienced symptoms in patients with cancer. These disturbances occur throughout the spectrum of cancer care from diagnosis, treatment, and long into survivorship. The pathogenesis of these symptoms and disturbances is based on common inflammatory pathways related to cancer and its’ treatments. The evaluation of sleep and circadian disorders requires an understanding of how these symptoms cluster with other cancer-related symptoms and potentiate each other. A thorough evaluation of these symptoms and disorders utilizing validated diagnostic tools, directed review of clinical information, and diagnostic testing is recommended. Treatment of sleep and circadian disturbance in cancer patients should be based on the findings of a detailed evaluation, including specific treatment of primary sleep and circadian disorders, and utilize integrative and personalised management of cancer-related symptoms through multiple pharmacologic and non-pharmacologic modalities. Recognition, evaluation, and treatment of sleep and circadian rhythm disturbance in cancer may lead to improved symptom management, quality of life, and outcomes.\ud \ud

Throughout the cancer continuum, patients are faced with the cancer- and treatment-related side effects that can have a negative impact on their overall quality of life. Cancer-related fatigue (CRF) and sleep deficiency are among the symptoms that patients and their caregivers most often experience. An increasing body of literature suggests that a strong correlation between CRF and sleep deficiency exists, indicating that they may be reciprocally related and that they may have similar underlying etiology. This paper aims at bringing together the opinions of leading cancer control (i.e., CRF and sleep) and oncology experts in order to increase the understanding of CRF and sleep deficiency's assessment, associated symptom clustering, symptom burden shared by caregivers, and CRF and sleep deficiency management in the cancer care context.

Sleep and circadian rhythm disturbance are among the most commonly experienced symptoms in patients with cancer. These disturbances occur throughout the spectrum of cancer care from diagnosis, treatment, and long into survivorship. The pathogenesis of these symptoms and disturbances is based on common inflammatory pathways related to cancer and its' treatments. The evaluation of sleep and circadian disorders requires an understanding of how these symptoms cluster with other cancer-related symptoms and potentiate each other. A thorough evaluation of these symptoms and disorders utilizing validated diagnostic tools, directed review of clinical information, and diagnostic testing is recommended. Treatment of sleep and circadian disturbance in cancer patients should be based on the findings of a detailed evaluation, including specific treatment of primary sleep and circadian disorders, and utilize integrative and personalised management of cancer-related symptoms through multiple pharmacologic and non-pharmacologic modalities. Recognition, evaluation, and treatment of sleep and circadian rhythm disturbance in cancer may lead to improved symptom management, quality of life, and outcomes.

PURPOSE. Pulmonary function testing (PFT) in patients with tracheostomies has been perceived as difficult to perform and clinically unreliable. We studied the feasibility, quality, repeatability and clinical significance of PFT. METHODS. Patients with tracheostomies that underwent PFT from 01/01/2010 to 2/29/2012 were identified. Clinical history and PFT data were reviewed retrospectively. RESULTS. Fifty patients (88% men) were identified. Forty-seven (94%) patients were able to perform PFT. Acceptable repeatability was obtained for FVC in 39(83%) and for FEV1 in 41(87%). Patients with tracheostomies showed difficulty in meeting ATS end-of-test criteria; only 9(19%) met plateau criteria and 25 (53%) had exhalation times of greater than 6 seconds. Obstructive pattern was observed in 30 (64%) and restrictive pattern in 9 (19%). DLCO measurements were attempted in 43 patients and satisfactorily obtained in 34 (79%). CONCLUSIONS. PFT can be performed with reliability in patients with tracheostomies, and they are useful for detecting and classifying types of lung dysfunction.

Patients with acute myeloid leukemia (AML) and myelodysplastic syndrome (MDS) treated with immune checkpoint inhibitors (ICIs) are at risk of pneumonitis as well as pneumonia (combined henceforth as ICI-related pulmonary complications). Little is known about the cellular and molecular mechanisms underlying ICI-related pulmonary complications. We characterized lymphocytes from bronchoalveolar lavage (BAL) fluid and peripheral blood from seven AML/MDS patients with pulmonary symptoms after ICI-based therapy (ICI group) and four ICI-naïve AML/MDS patients with extracellular bacterial or fungal pneumonias (controls). BAL T cells in the ICI group were clonally expanded, and BAL IFNγ+ IL-17− CD8+ T and CXCR3+ CCR6+ Th17/Th1 cells were enriched in the ICI group. Our data suggest that these cells may play a critical role in the pathophysiology of ICI-related pulmonary complications. Understanding of these cell populations may also provide predictive and diagnostic biomarkers of ICI-related pulmonary complications, eventually enabling differentiation of pneumonitis from pneumonia in AML/MDS patients receiving ICI-based therapies.

IntroductionSince immune checkpoint inhibitor (ICI) blockade has become standard therapy for many cancers, immune-related adverse events (irAEs) have increased. ICI-pneumonitis is infrequent but potentially fatal. In cases not responsive to corticosteroids, additional immunosuppression is recommended. Data for use of infliximab in ≥ grade 3 pneumonitis is sparse.Materials and MethodsA retrospective review of patients who received infliximab for ICI-pneumonitis from March 2016 to October 2018 was performed. Clinical characteristics were reviewed.ResultsNine patients (44% women) with ≥ grade 3 pneumonitis were included. Concurrent/prior irAEs were present in 55%. Bronchoscopy was performed in 67%. Median corticosteroid dose was 1.2 mg/kg prior to infliximab, and time from administration of corticosteroids to infliximab ranged from 2 to 34 days. Four patients improved, but the remainder died.ConclusionWe report improvement of ICI-pneumonitis with infliximab in 4 out of 9 patients in a small, retrospective cohort. Further prospective randomized controlled trials are needed.

The advancement of wearable technologies provides opportunities to continuously track individuals’ daily activity levels and sleep patterns over extended periods of time. These data are useful in examining the reciprocal relationships between physical activity and sleep at the intrapersonal level. The purpose of this study is to test the bidirectional relationships between daily activity levels and sleep duration. The current study analyzed activity and sleep data collected from a Fitbit device as part of a 6 month employer-sponsored weight loss program. A total of 105 overweight/obese adults were included (92% female, 70% obese, and 44% Hispanic). Multilevel models were used to examine (a) whether daily active and sedentary minutes predicted that night’s sleep duration and (b) whether sleep duration predicted active and sedentary minutes the following day. Potential extended effects were explored by using a 2 day average of the activity minutes/sleep duration as the predictor. No significant relationships between active minutes and sleep duration were found on a daily basis. However, having less sleep over two nights than one’s usual level was associated with an increased likelihood of engaging in some physical activity the following day. There was a significant bidirectional negative association between sedentary minutes and sleep duration for both the daily and 2 day models. Data from wearable trackers, such as Fitbit, can be used to investigate the daily within-person relationship between activity levels and sleep duration. Future studies should investigate other sleep metrics that may be obtained from wearable trackers, as well as potential moderators and mediators of daily activity levels and sleep.

The primary aim of the study was to estimate the effect of sleep duration on prospective type 2 diabetes (T2D) risk across demographic characteristics and follow-up periods, and test BMI as a mediator and moderator. Data included adults (M(age) = 39.0 ± 12.7y) born in the US or Mexico recruited from 2001-2012 in a Mexican American cohort study conducted in Houston, Texas (n=15,779). Participants completed self-reported questionnaires at baseline related to health, health behaviors (sleep duration, physical activity, smoking, drinking) and sociocultural factors, and were followed up annually. Cox proportional hazard models estimated hazard ratios (HR) for the effect of sleep duration on T2D diagnosis at follow-up. Of the participants, 10.3% were diagnosed with T2D. Self-reported ≤5 hours of sleep, compared to 7-8 hours, at baseline predicted greater risk for T2D (HR=1.32, p=.001), yet was no longer significant after adjusting for sociodemographic characteristics and BMI. Notably, those with BMI < 25 kg/m(2) reporting ≤5 hours of sleep were at significant risk for T2D at 3 (HR=4.13, p=.024) and 5 year follow-up (HR=3.73, p=.008) compared to 7-8 hours. Obesity status accounted for 31.6% and 27.3% of the variance in the association between ≤5 and 6 hours of sleep and increased T2D risk, respectively. Results highlighted the mediating and moderating role of BMI, and its effect on T2D risk at earlier follow-up among those without obesity. T2D prevention and control for Mexican American adults should consider the role of chronic sleep loss.

Context Episodic dyspnea is one of the most common, debilitating, and difficult-to-treat symptoms. Objective We conducted a pilot study to examine the effect of prophylactic fentanyl buccal tablet (FBT) on exercise-induced dyspnea. Methods In this parallel, double-blind randomized placebo-controlled trial, opioid-tolerant patients were asked to complete a six-minute walk test (6MWT) at baseline and then a second 6MWT 30 minutes after a single dose of FBT (equivalent to 20–50% of their total opioid dose) or matching placebo. We compared dyspnea Numeric Rating Scale (NRS, 0–10, primary outcome), walk distance, vital signs, neurocognitive function, and adverse events between the two 6MWTs. Results Among 22 patients enrolled, 20 (91%) completed the study. FBT was associated with a significant within-arm reduction in dyspnea NRS between 0 and six minutes (mean change −2.4, 95% CI −3.5, −1.3) and respiratory rate (mean change −2.6, 95% CI −4.7, −0.4). Placebo was also associated with a nonstatistically significant decrease in dyspnea (mean change −1.1). Between-arm comparison of dyspnea scores in the second 6MWT favored FBT, albeit not statistically significant (estimate −0.25, P = 0.068). Global impression revealed more patients in the FBT group than placebo group reporting their dyspnea was at least "somewhat better" in the second 6MWT (4 of 9 vs. 0 of 11, P = 0.03). The other secondary outcomes did not differ significantly between arms. Conclusions This study supports that prophylactic FBT was associated with a reduction of exertional dyspnea and was well tolerated. Our findings support the need for larger trials to confirm the therapeutic potential of rapid-onset opioids.

Obstructive sleep apnea (OSA) has been investigated the most within the spectrum of sleep-related breathing disorders in cancer. The purpose of this review is to describe the biological pathways and review the epidemiological studies regarding OSA and cancer, and to additionally explore the spectrum of sleep-related breathing disorders in cancer. Murine models have elucidated intermittent hypoxia and sleep fragmentation as oncogenic, and large epidemiologic studies have identified increased cancer incidence among those with OSA and hypoxemia. Central sleep apnea (CSA) may develop in those using opioids for pain control. Sleep-related hypoventilation should be considered in those with underlying pulmonary dysfunction, vocal cord abnormalities, and neuromuscular weakness. Cancer patients are at risk of developing sleep-related breathing disorders in the form of OSA, CSA, or sleep-related hypoventilation. The impact of sleep-related breathing disorders on cancer may have ramifications for the prevention and treatment of cancer.

Background Patients who have pleural effusions typically undergo thoracentesis with examination of pleural fluid in their initial assessment. However, limited data are available on the diagnostic yield of pleural fluid bacterial cultures, fungal and acid-fast bacilli (AFB) smear and cultures in cancer patients. Methods We performed a retrospective cohort study of consecutive patients who had new onset pleural effusions and underwent an initial thoracentesis. The primary outcome was diagnostic yield of pleural fluid bacterial cultures, fungal and acid-fast bacilli smear and cultures. Results Of 1637 patients, 1547 (94%) had evidence of active malignancy and 1359 (83%) had evidence of metastatic disease. Of the 1637 patients, 542 (33%) had high clinical suspicion of pneumonia within 14 days prior to thoracentesis. Only 14 patients (1.1%) had positive pleural fluid bacterial cultures, and only 6 of these positive cultures met the criteria for true pleural space infection. Conclusions The incidence of positive results from pleural fluid bacterial, fungal and acid-fast bacilli in cancer populations is very low. Unless there is a suspicion for infection, microbiological analysis should be ordered selectively.

BACKGROUND. Bronchoscopy is a safe procedure, but current guidelines recommend transfusion for platelets less than 20 K/μL. Studies of bronchoscopy in thrombocytopenia are limited. OBJECTIVES. Our objective was to evaluate the incidence of bleeding with flexible bronchoscopy in those with thrombocytopenia especially those less than 20 K/μL. METHOD. We performed a retrospective review of all flexible bronchoscopies between 6/1/2008 and 12/31/2010. Biopsies and therapeutic procedures were excluded. Chi-squared, Fisher’s exact and rank-sum test were conducted to evaluate associations of clinically significant bleeding RESULTS. There were 1711 patients who underwent 2053 flexible bronchoscopies. Cancer diagnosis included hematologic (61.3%) and solid organ malignancy (34.9%). Half of the bronchoscopies had moderate to severe thrombocytopenia (

Objectives To examine the role of health behaviors (eg, physical activity, sedentary behaviors, and diet) in the relationship between sleep (ie, duration and quality) and BMI among African American adults. Design A cross-sectional self-report questionnaire included questions related to health and health-related behaviors. Setting This study was based on data from the CHURCH study, which aimed to address cancer health disparities among church-going African Americans in Houston, TX. Participants African American adults were recruited from three large community churches. The sample included a total of 1837 participants (75.2% female; mean age 48.2 ± 13.7y; mean BMI 32.0 ± 7.5 kg/m2). Measurements Linear regression models and path analyses controlling for demographic characteristics and depression estimated the associations between sleep and BMI as well as the mediating roles of health behaviors. Results The average self-reported sleep duration was 6.2 ± 1.5 h/night with 61%, 35.8%, and 1.6% reporting short (≤6 h/night), normal (7–9 h/night), and long sleep (≥10 h/night), respectively. Short sleep was related to greater BMI (b = 1.37, SE = 0.38, P = .01), and the relationship was mediated by sedentary behaviors (est. = 0.08, SE = 0.04, 95% CI: 0.02, 0.17). Conclusions Short sleep and poor quality sleep was related to poor diet and physical activity-related health behaviors, and BMI. The link between sleep and obesity is, in part, due to energy imbalance from increased sedentary behavior.

BackgroundThoracentesis using suction is perceived to have increased risk of complications, including pneumothorax and re-expansion pulmonary oedema (REPO). Current guidelines recommend limiting drainage to 1.5 L to avoid REPO. Our purpose was to examine the incidence of complications with symptom-limited drainage of pleural fluid using suction and identify risk factors for REPO.MethodsA retrospective cohort study of all adult patients who underwent symptom-limited thoracentesis using suction at our institution between January 1, 2004 and August 31, 2018 was performed, and a total of 10 344 thoracenteses were included.ResultsPleural fluid ≥1.5 L was removed in 19% of the procedures. Thoracentesis was stopped due to chest discomfort (39%), complete drainage of fluid (37%) and persistent cough (13%). Pneumothorax based on chest radiography was detected in 3.98%, but only 0.28% required intervention. The incidence of REPO was 0.08%. The incidence of REPO increased with Eastern Cooperative Oncology Group performance status (ECOG PS) ≥3 compounded with ≥1.5 L (0.04–0.54%; 95% CI 0.13–2.06 L). Thoracentesis in those with ipsilateral mediastinal shift did not increase complications, but less fluid was removed (pConclusionsSymptom-limited thoracentesis using suction is safe even with large volumes. Pneumothorax requiring intervention and REPO are both rare. There were no increased procedural complications in those with ipsilateral mediastinal shift. REPO increased with poor ECOG PS and drainage ≥1.5 L. Symptom-limited drainage using suction without pleural manometry is safe.

Dyspnea or breathlessness is one of the most distressing symptom experienced by patients with advanced disease such as cancer, end-stage chronic obstructive pulmonary disease, and heart failure. It can be either continuous or episodic (more frequent). Management is usually interdisciplinary and individualized to a given patient. A combination of strategies, such as use of opioids, oxygen, short-term steroids, and counseling, is likely to reduce the symptom burden related to dyspnea.

Opioids adversely influence respiration in five distinct ways. Opioids reduce the respiratory rate, tidal volume, amplitude, reflex responses to hypercapnia and hypoxia, and arousability related necessary for respiratory adaptive responses. Opioids cause impairment of upper pharyngeal dilator muscles leading to obstructive apnea. Opioids cause complex sleep disordered breathing (SDB) consisting of central sleep apnea and obstructive sleep apnea. Clinically opioids worsen preexisting SDB. Recent studies have shown increased morbidity and mortality in patients receiving opioids for chronic noncancer pain and chronic obstructive pulmonary disease, which appear to be related to cardiovascular events, not overdose. Both patient populations are at risk for sleep disordered breathing and increased risk for adverse cardiovascular events on opioids for dyspnea or pain. This review discusses the influence of opioids on respiration and SDB and will review the adverse respiratory and cardiovascular effects of opioid use in at risk populations. Recommendations regarding management will follow as a summary.

Placement of an indwelling pleural catheter is an established modality for symptom relief and pleurodesis in the treatment of malignant pleural effusion. Concerns remain regarding possible infectious complications, risk of hemorrhage, and the rate of pleurodesis with the use of pleural catheters in the treatment of hematologic malignancies.The goals of our study were: (1) to evaluate the safety and cumulative incidence of pleurodesis with indwelling pleural catheters for patients with hematologic malignancies, and (2) to evaluate overall survival of this cohort of patients with pleural effusions.We performed a retrospective review of 172 patients with a hematologic malignancy who underwent placement of an indwelling pleural catheter between September 1997 and August 2011 at the University of Texas MD Anderson Cancer Center in Houston, Texas. A competing risk model analysis was used for complications and pleurodesis. Analysis was based on each patient's first intrapleural catheter.There were 172 patients with lymphoma (58%), acute (16%) or chronic leukemia (16%), or multiple myeloma (10%). The effusions were characterized as malignant (85.5%), infectious (4.1%), volume overload (4.7%), or therapy-related (4.7%). Chylothorax was found in 20.1%. Pleural biopsies were obtained from 13 patients. The cumulative incidence of all complications was 13.6%, and the cumulative incidence of all significant catheter-related complications was 9.5%. The incidence of empyema was 2.9%, and major bleeding (requiring transfusion or intervention) was 1.7%. Thirty-day procedure-associated mortality was 0.6%. The cumulative incidence of pleurodesis at 180 days was 50%, with a median time to pleurodesis of 81 days for the entire cohort.Indwelling pleural catheters appear to be safe for patients with hematologic malignancies. Complications and the cumulative incidence of pleurodesis are comparable to those reported for patients with solid organ malignancies.

Background. Sleep disturbance is a prominent complaint of cancer patients. Most studies have focused on insomnia and cancer-related fatigue. Obstructive sleep apnea (OSA) has been reported in small studies and case reports. Methods. In a retrospective review of patients who underwent formal sleep evaluation and polysomnography (PSG) from 2006 to 2011, 56 patients with tumors in the head and neck region were identified. Clinical characteristics, sleep-related history, and PSG data were reviewed. Results. Most patients had active cancer (80%), and the majority had squamous pathology (68%). Prominent symptoms included daytime fatigue (93%), daytime sleepiness (89%), and snoring (82%). Comorbid conditions primarily included hypertension (46%) and hypothyroidism (34%). Significant sleep-related breathing disorder was noted in 93% of patients, and 84% met clinical criteria for OSA. A male predominance (77%) was noted, and patients were not obese (body mass index Conclusion. Sleep-related breathing disorder was common in patients with tumors in the head and neck region referred for evaluation of sleep disruption, and most met clinical criteria for OSA. Daytime fatigue and sleepiness were the most common complaints. OSA was prevalent in male patients, and most with OSA were not obese. Architectural distortion from the malignancy and/or treatment may predispose these patients to OSA by altering anatomic and neural factors. A heightened clinical suspicion for sleep-related breathing disorder and referral to a sleep specialist would be beneficial for patients with these complaints.

Background: In the past decade, targeted therapy with antiangiogenic drugs has become standard of care for most types of metastatic, progressive thyroid cancer. While these drugs were thought initially to be less toxic than traditional chemotherapy, they can have rare but serious and fatal toxicities. Once such toxicity that has been reported in other tumor types is upper airway fistula formation, which can be life-threatening. Summary: Here, we describe three patients treated with antiangiogenic tyrosine kinase inhibitors at two academic institutions who developed aerodigestive fistula. All three patients had risk factors for fistula formation, which included external beam radiation and/or large tumor with invasion of the tracheal wall. Conclusions: Fistula formation is a known but rare side effect of antiangiogenic tyrosine kinase inhibitors. Knowledge of the risk factors that may predispose thyroid cancer patients to this serious adverse event is vital prior to prescribing antiangiogenics. Particular caution should be observed when using these drugs in patients undergoing radiation therapy or surgery, or in patients whose tumor is invading vital structures of the neck, as they may be at higher risk of developing this rare complication. In these patients, antiangiogenic tyrosine kinase inhibitors should be used cautiously, patients should be aware of the risk, and physicians should monitor patients for symptoms of fistula.

A middle-aged man with history of squamous cell cancer of the base of the tongue, who was treated with chemoradiation and neck dissection 5 years ago, presented with loud snoring, gasping arousals at night and excessive daytime sleepiness with an Epworth Sleepiness Score of 15. He denied any diurnal respiratory symptoms. Routine follow-up since completion of cancer treatment revealed no evidence of disease recurrence and stable mild supraglottic oedema on laryngoscopic evaluation. Physical examination revealed a body mass index of 28.9 kg/m2, Mallampati II airway, firmness on the right side of his neck secondary to prior radiation therapy, no stridor and clear lung fields. A split-night diagnostic-titration study was performed and revealed severe obstructive sleep apnoea (OSA) with an oxygen saturation nadir of 50% (figure 1). Despite …

Cancer-related fatigue (CRF) continues to be a major concern of patients and providers of cancer care. The symptoms are debilitating and can persist for many years after the cancer diagnosis and therapy. Further research is required to address the mechanisms of illness, including a better understanding of the complex interplay between the sleep system, circadian rhythms, inflammation, and the hypothalamic-pituitary axis. Genetic analysis and genomic studies need to be done to better understand which patients may be prone to CRF and which therapies may exacerbate these symptoms. Attention must be focused on understanding which comorbidities, including mood disturbance, sleep disturbance deconditioning, cardiovascular, and endocrine function, contribute to CRF.

A case of a 55-year-old woman with iatrogenic vocal cord trauma and sleep-related symptoms is reported. In particular, this case highlights sleep-disordered breathing as a delayed complication after iatrogenic vocal cord trauma. The patient developed acute stridor from a contralateral vocal cord hematoma following vocal fold injection for right vocal cord paralysis. Acute respiratory symptoms resolved with oxygen, steroids, and nebulized therapy, but nocturnal symptoms persisted and polysomnography revealed sleep-related hypoventilation and mild obstructive sleep apnea. Positive pressure therapy was successfully used to ameliorate her symptoms and treat sleep-disordered breathing until her hematoma resolved. In addition to the typically acute respiratory symptoms that may result from vocal cord dysfunction, sleep-disordered breathing may also present as a significant subacute or chronic problem. Management of the acute respiratory symptoms is relatively well established, but clinicians should be alert for more subtle nocturnal symptoms that may require further study with polysomnography.

Persistent airway inflammation, mucus production, and airway hyperreactivity are the major contributors to the frequency and severity of asthma. Why lung inflammation persists in asthmatics remains unclear. It has been proposed that Fas-mediated apoptosis of inflammatory cells is a fundamental mechanism involved in the resolution of eosinophilic airway inflammation. Because infiltrating eosinophils are highly sensitive to Fas-mediated apoptosis, it has been presumed that direct ligation of Fas on eosinophils is involved. Here, we utilize adoptive transfers of T cells to demonstrate that the delayed resolution of eosinophilia in Fas-deficient mice is a downstream effect of Fas deficiency on T cells, not eosinophils. Interestingly, the mice that received Fas-deficient T cells, but not the controls, developed a persistent phase of inflammation that failed to resolve even 6 wk after the last challenge. This persistent phase correlated with decreased interferon (IFN)γ production by Fas-deficient T cells and could be reproduced with adoptive transfer of IFNγ-deficient T cells. These data demonstrate that Fas deficiency on T cells is sufficient for the development of long-term allergic airway disease in mice and implies that deregulation of death receptors such as Fas on human T cells could be an important factor in the development and/or chronic nature of asthma.

Cancer-related fatigue is a common symptom in cancer patients which commonly occurs in relation to sleep disturbance. We report a case of a 35-year-old breast cancer survivor, in whom polysomnography and multiple sleep latency testing were utilized to objectively quantify the contribution of excessive daytime sleepiness to the patient’s cancer-related fatigue.

To assess the potential use of peripheral blood CD4 + T-lymphocyte counts (CD4 + counts) as a clinically useful biological marker to identify specific immunocompromised patients (without HIV infection) at high risk for Pneumocystis carinii pneumonia (PCP).Prospective observational study.Three hundred seventy-five-bed tertiary-care urban referral teaching hospital, and 250-bed community-based referral hospital.One hundred seventy-one consecutive confirmed HIV-seronegative hospitalized and ambulatory adults, including 22 patients with active PCP, 8 patients with bacterial pneumonia, 24 persons in two groups considered at high clinical risk, 38 persons in two groups considered at low or undefined risk, and 79 persons in four groups considered not at risk for PCP (including healthy individuals).Compared to counts in healthy individuals, median CD4 + counts were significantly decreased in patients with active PCP (61 cells/microL vs 832 cells/microL; p = 0.001) where 91% of patients had a CD4 + count300 cells/microL at the time of PCP diagnosis. Median CD4 + counts were also reduced in the high clinical risk groups of recent organ transplant recipients (117 cells/microL; p = 0.007), 64% with300 cells/microL, and patients receiving chemotherapy (221 cells/microL; p0.01), 80% with300 cells/microL. For the low or undefined clinical risk groups, the median CD4 + counts were not significantly reduced, although 39 to 46% of individuals receiving long-term corticosteroid therapy (alone or in combination with other agents) had CD4 + counts300 cells/microL. Median CD4 + counts in individuals considered not at risk for PCP were similar to those in healthy subjects. Compared to counts in patients with active PCP, median CD4 + counts were significantly higher in bacterial pneumonia patients (486 cells/microL; p0.05), but similar to those in healthy subjects.These data suggest that for immunosuppressed persons without HIV infection (especially in low or undefined PCP risk groups), CD4 + counts may be a useful clinical marker to identify specific individuals at particularly high clinical risk for PCP and may help to guide chemoprophylaxis.

Information related to the clinical characteristics and isolated microbes associated with lung abscesses comparing immunocompromised (IC) to non-immunocompromised (non-IC) patients is limited. A retrospective review for 1984–1996 identified 34 consecutive adult cases of lung abscess (representing 0·2% of all cases of pneumonia), including 10 non-IC and 24 IC patients. Comparison of age, gender, tobacco use, pre-existing pulmonary disease or recognized aspiration risk factors were not significantly different between the two groups. Upper lobe involvement accounted for the majority of cases, although multi-lobe involvement was limited to IC patients. There were no differences in the need for surgical intervention, and mortality was very low for both groups. Anaerobes were the most frequent isolates for non-IC patients (30%), whereas aerobes were the most frequent isolate for IC patients (63%). Importantly, certain organisms were exclusively isolated in the IC group and multiple isolates were obtained only from the IC patients. Thus, comparing non-IC to IC patients, clinical characteristics may be similar whereas important differences may exist in the microbiology associated with lung abscess. These findings have important implications for the clinical management of these patient groups, and support a strategy to aggressively identify microbial agents in abscess material.