Public Health Interventions in Cystic Fibrosis-Juniper Publishers

International Journal of Pulmonary & Respiratory Sciences

 

The United States invests billions of dollars dedicated to funding research projects throughout the country. For instance, President Obama's fiscal budget for the National Institute of Health was 31.3 billion dollars. In efforts to conduct groundbreaking research; however, the budget was decreased due to sequestration from Congress. Consequently, the National Institute of Health has lost over 1.7 billion in funding for FY 2014, this loss will affect over 700 research grants overall due to sequestration (www.nih.gov, 2014, para.4). However, the National Institute for Health invigorates the U.S to stay number one among developed world healthcare providers, it also has advanced medical and scientific technology, by creating sound treatments and preventative measures for those with cystic fibrosis and other chronic diseases that plague U.S citizens alike. Unfortunately, budget cut to the NIH will affect clinical trials, competitive research grants and will poorly impact research prevention overall in the Country. Therefore, budget cuts and cystic genetic mutations affect our government, public facilities and private institutions overall. By, crippling their ability to conduct viable research cystic research will plummet without funding (www.cff.org, 2013). Without, concise clinical research trials the NIH and private researchers who receive grants to study cystic fibrosis will not be able to conduct research trials which help to enroll participants that could offer solutions to unraveling the genetic valley of gene mutations associated with cystic fibrosis. Cystic fibrosis has affected both public health in the United States and global communities, governing bodies research capabilities, and interventional policy creation over the past twenty years.

Introduction

First, cystic fibrosis impacts public health in the U.S. through biological, genetic and molecular factors that are both positive and negative. Regretfully, some aspects of cystic fibrosis are negative upon those suffering from the disease and the governing bodies in which are needed in funding programs and health systems that are essential in treating the disease. Biomedical research has advanced in studying the specific gene mutations that occur in cystic fibrosis while genetic epidemiology has allowed for longer life spans in those with the CFTR gene mutation. People with cystic fibrosis are living to 37.5 years of age and experienced improved public health care impacts as opposed to their global partners in developing worlds (www. cdc.org.gov, 2012). However, this positive growth in treating and care has only grown due to the implementation of sound clinical research and higher education in America [1-8]. Public health measures throughout the country seek to prevent disease states as opposed to responding to disease states as older models of treating diseases after the initial diagnosis has changed. Cystic fibrosis has impacted public health by: identifying those with disease states early on, elongating life in CF patients, and medical practices/providers are seeking to identify those with disease. However, the necessary medical treatments like: antiviral, antibiotics, life support and gene therapies can be costly among all judicial branches in effort to decode the onslaught of mutations that can occur in the CFTR gene [7].

Secondly, some ways governmental contribution roles are implicated is in research prevention of cystic fibrosis has impacted experienced mortality rates associated with the disease state. As stated earlier, those with cystic fibrosis are experiencing much longer lives as opposed to twenty years ago. Governmental research via clinical trials are vital to preventing the spread of cystic fibrosis in newborns that remain undiagnosed without the proper testing for CF and sound institutional procedures. For example, most states within the U.S. require infant testing for cystic fibrosis at delivery times or before three months of age. Fortunately, these early testing requirements have been instrumental in diagnosing and ensuring timely treatment for infants with CF. These timely clinical tests have been an essential part of cystic fibrosis sufferers experiencing better quality of life. With the CFTR mutation amino acids are stagnant and allow for increased mucus production in the CF gene mutation faltering potassium and sodium levels in patients. This has an extreme effect on private intuitions and governments alike. There are not many species which experience this gene mutation except in the human genome. So, identifying people with the mutation is essential in treating the disease and increasing awareness on testing capabilities among those of European heritage. The U.S. funnels billions of dollars into research annually by supporting the National Institute of Health's budget. Ensuring access to healthcare, quality care, adequate hospitals, clinics and preserving federal support to HIH is essential to positive influences from governing systems (www.nih.gov., 2012)

Methods Used to Diagnose Cystic Fibrosis in Infants

a. Cf testing
b. Infant test
c. Sweat test

However, one can become an advocate and delve into governmental cystic fibrosis processes by: volunteering, meeting with congressional representatives and strengthening the Food and Drug Administration's overall. These all can help in the methods utilized in public health prevention initiatives when attempting to fund research associate with cystic fibrosis. The U.S and its European partners have taken on the fight against cystic fibrosis in measures to prevent the disease from occurring more frequently through timely testing.

Thirdly, biological, genetic, molecular indicators that impact public health practices are experienced by millions in the U.S. Biological indicators of public health impacts both patients and governments negatively overall. Therefore, without the proper research to identify mutative genes from all disease states. These spectral norms wouldn’t exist and public health would be greatly deterred among all stakeholders in the U.S. Other biological indicators can be from environmental and molecular variance in the world in which we live and the internal processes from all human, plant and animals. Also, public health impacts are greatly dependent upon the educational, planning, implemented, and evaluation of molecular factors associated with quality care among citizens. Fortunately, new discoveries in large animal studies like pigs are showing great resemblance to CFTR gene mutative phenotypes in animals (Fisher, 2011). Which would greatly improve the understanding of the gene mutation in the human specifies. Although, in earlier studies there were no comparative mutations in small animals like mouse, and ferrets to suggest somatic nuclear cell transference of a CFTR gene type (Warwick, 1963).

Last, but not least, there are several types of public health intervention strategies available to those with cystic fibrosis. From sweat testing early on it a concise indicator for infants with the disease. Even if infants are diagnosed at five to six months early intervention is key in improving life spans among cystic fibrosis patients. This has helped medical providers and parents identify children inflicted with the disease early on. This has led to increasing the lifespan of those with the CFTR gene mutation. Also, other interventions include educating the public on cystic fibrosis symptoms, while stressing the importance of intervention early on. For example, in the U.S. every state tests for the CFTR gene after delivery. There are global initiatives to support research on cystic fibrosis like the United Kingdom's Cystic Trust Research Strategy which increases awareness and raises millions of dollars to support key biomedical, pharmaceutical research.

Conclusion

In conclusion, cystic fibrosis has affected both public health in the United States and global communities, governing bodies research capabilities, and interventional policy creation over the past twenty years. Fortunately, it has inspired great clinical trials and pharmacokinetic practices that continue to p [positively influence the lives of thousands suffering from the disease process. Governing bodies will continually fight against the disease which continually evades the phenotypes of thousands of Eastern Europeans among all populations around the globe. Governmental roles in the CFTR gene mutation are to seek research methods to decrease the prevalence of the disease state. By, family planning, genetic testing, gene sequencing and educating the public are all essential in government processes to fight the F508 gene mutation (Table 1). 

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Pulmonary Hydatid Cysts Causing Massive Hemoptysis and Hydatoptysis Treated Surgically: A Case Report and Review of Literature-Juniper Publishers

International Journal of Pulmonary & Respiratory Sciences

A 52 years old male nonsmoker, presented with a history of shortness of breath, cough, hemoptysis and upper right upper quadrant abdominal pain for the last one month. No history of loss of weight or appetite. Patient was diagnosed six months ago as hydatid disease of liver and lung and he was commenced on oral scolicidial agent Abendazole by referring hospital. Computed tomographic scan of thorax and abdomen Demonstrated large bilateral pulmonary and hepatic cysts with typical radiological findings of hydatid cyst. Pulmonary cysts were excised by staged procedure and later on hepatic cyst were drained by interventional radiologist.

Keywords: Echinococcus granuloses liver; Lung; Hemoptysis; Hypertonic saline; Surgery

Background

Parasitic infestation by Echinococcus Granuloses was described by Rudolphy in 1808 as a hydatid cyst also this is known as echinococcosis and hydtasois [1]. There are four other species of Echinococcus which can affect human but among all Echinococcus Granulosus is the most common cause of zoonotic parasitic infection (Table 1). Epidemiologically, this disease prevails almost all over the world but there are endemic areas as Australia, New Zealand, South and Central America, Middle East, Sub Saharan Africa, Russia, China, Turkey [2,3].

Case

A 52 years old male smoker presented to our tertiary care hospital with history of cough and hemoptysis. He was diagnosed six months ago in the referral hospital as case of hydatid disease of lung and was commenced on Albendazole 800 mg daily. He had scattered hemoptysis for 3-4 times in a month but prior to admission he had massive hemoptysis. On clinical examination he had dyspnea with the respiratory rate of 24/min, no cyanosis or jaundice, breath sounds were decreased over right hemi thorax. Laboratory tests revealed Hemoglobin (8gm/dl), liver enzymes Alanine Transaminase (ALT) 28U/lit Aspartate Transaminase (AST) 16U/lit, Alkaline phosphatase 300 U/lit. Chest radiograph and CT scan of thorax and upper abdomen showed large bilateral pulmonary and hepatic cysts. Immunoglobulin G for echinococcus was positive. As the patient had massive hemoptysis and was symptomatic urgent surgery was planned. Surgical approach was right thoracotomy and we found a very large cyst densely attached and compressing the lung parenchyma. A purse string suture was placed and in the center of cyst and surrounding lung tissues were covered with gauze soaked in hypertonic 14% saline. A 14 F catheter was inserted in the cyst and tightly snugged to avoid any spillage then 200 ml of 14% hypertonic saline was installed in the cyst cavity and left for five minutes after that fluid was sucked, catheter was removed and purse suture snugged. With meticulous dissection cyst was removed in total sparing the lung parenchymal tissues (Figures 1 & 2). The left side cysts were removed as staged procedure after four weeks in similar fashion. Histopathology report showed dead daughter cysts and no live parasite (Figure 3).

Discussion

Echinococcosis also known as hydatisosis is the most common parasitic disease caused by larval cestodes. This parasite harbors in two hosts: primary and intermediate to complete its life cycle. Livestock animals like sheep, goat, horse, pigs, camels as well as humans are intermediate host while the Carnivorous animals like wolves, dogs, are definite host (Figure 4A-4F). Humans are infected accidently by ingesting the vegetables, fruits and water contaminated by soil with dog stool containing eggs. Echinococcus eggs can survive for a year outside in the atmosphere and are the main source of contamination [4-6]. On ingestion eggs hatch to oncosphere larva in the small intestine thereafter, enter in to the blood stream and is carried to the liver by portal circulation or can by pass to pulmonary system and then develop to metacestodes. These fluid filled cysts are composed of hundreds of protoscolices, which are the source leading to formation of daughter cysts or mature worm (2-3 mm long). This life cycle is usually completed in 2-7 weeks. Human to human spread is not possible as carnivores’ (definite host) is required to complete the life cycle. Hydatid cysts are tri layers, (pericyst, laminated and germinal) filled with nutritious fluid that promote larval growth [7,8] (Figure 5).

The best diagnostic modality is imaging chest x-ray and CT scan of thorax and abdomen [9,10]. Serological methods, Weinberg complement fixation and Casoni tests were used in the past and their yield is very poor. ELISA and IHA are most widely used serological tests [11]. Patients with pulmonary hydatid disease are initially asymptomatic. Most of the symptoms are either due to mass effect of cyst on neighboring structures or rupture of cyst leading to anaphylactic reaction, hemoptysis, hydatoptysis, infection, pneumothorax and empyema (Table 2). Clinically patient can present with chest pain, fever, tachycardia, hemoptysis, and hydatoptysis. Pulmonary hydatid cysts increase in size faster than in other parts of body probably due to elastic nature of lungs and negative intrathoracic pressure [12-14].

Treatment is chemotherapy and surgery. The medical treatment is very beneficial in patients with multisystem (disseminated) disease and can be given as neodjuvant therapy or adjuvant therapy in patients at risk of spillage during the surgery. The commonly used chemotherapeutic drugs are Mebendazole, Albendazole, Benz imidazole and Praziquantal. Albendazole is preferred because of its better bioavailability and the dose is 15mg/kg body weight per day in two daily doses approximately 800mg daily dose for minimum 3-6 months. It is not recommended in pregnancy particularly in first trimester due to its teratogenicity [15-18]. Horton et al. [19] treated 500 patients of Echinococcosis giving those 800 mg of Albendazole daily two and half cycles with 14 days interval. After evaluation of 250 patients only 47 required surgery and resected specimen demonstrated that only five patients have viable parasite. Recurrence rate in patients who received preoperative Albendazole as compared to those who did not receive Albendazole was 18.75& 4.16 % respectively. In medical literature Little et al. [20] reported recurrence rate of 22%, Mottaghlan and sadi observed 11.3%. Medical treatment alone is not enough to eradicate the disease once there are cystic lesions in lung and liver [19,20].

Radical Surgical resection of host tissues and entire cyst is mandatory if patient is symptomatic or any signs of infection or invasion in to surrounding structures. Postoperative chemotherapy for 1-2 years is recommended. Surgical approach is designed according to the location of the cysts. Most common surgical approaches are thoracotomy, median sternotomy and video assisted thoracoscopic resection. The basic surgical principal is that spillage of cyst contents should be avoided and adjacent tissues should be packed with gauze soaked in hypertonic saline solution (15%,20%) to avoid contamination. In case of cyst rupture during surgery or if cyst is infected, after the removal of germinal layer its recommended to wash the cyst cavity with hypertonic saline solution [21]. Dekak et al. [22] reported 202 patients who underwent surgery out of 422 cases. Enucleation, capitonage, segmentectomy, and lobectomy were the procedures performed [22]. Biswas & Burhan et al. [23] reported 26 and 24 cases respectively which were treated surgically. Ashok et al. [24] reported 33 cases out of 72 who required surgery [24].

Liver is the most common site of hydatid cyst formation, right lobe and left lobes are affected 60-75% and 20% respectively. Hepatic cysts generally remain asymptomatic for long time. The most common complication is intrabillary rupture 3-17% or rarely can rupture in to pericardial, pleural or peritoneal cavity, and neighboring organs in 20-50% of cases. Sometimes cysts develop secondary bacterial or fungal infection. The best diagnostic modality is Ultrasound and Spiral CT scan. ERCP can be helpful for diagnosis of biliary rupture or communication. Liver hydatid cyst rupture can be categorized as contained, communicating or direct. Reported incidence of communicating rupture in to biliary system is 44-64% [25]. The patient with intrabillary rupture present with right upper quadrant pain, obstructive jaundice, fever, cholangitis and sepsis (Table 2). There are multiple treatment modalities for the management of liver hydatid disease and surgery is reserved for complicated cysts. Rupture of the cyst into adjacent organs, complicated with biliary fistula, compression of adjacent vital structures and cysts with infection or hemorrhage require surgical intervention. Surgery is also recommended for cysts with many daughter vesicles that are not amenable to percutaneous treatment (WHO stage CE2 and CE3b) [26] (Table 3). If the cyst diameter is more than 10cm and or percutaneous facilities are not available then surgery is advisable. The other management options recommended by WHO are drug therapy (Albendazole) for stage CE1 and CE3 a provided the cysts are less than 3cm. If because of any reason medical management is not feasible then percutaneous treatment with puncture, aspiration, injection and respiration (PAIR) is the alternative. Combination treatment with PAIR and Albendazole is recommended for stage CE1 and CE3 that are more than 5cm in size [27-29].

Conclusion

In conclusion we treated a patient who had simultaneous hepatic and bilateral pulmonary hydatid cysts who presented with hemoptysis and right abdominal upper quadrant pain. The pulmonary hydatid cysts were resected as staged procedure and liver cysts were treated with PAIR and Albendazole therapy for six months. Our improvised technique of installation of hypertonic saline in the cyst prior to surgical dissection is effective and safe.

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Effect of Police Confinement Training Period on Respiratory Muscle Power and Hemoglobin in Khartoum State, Sudan-Juniper Publishers

International Journal of Pulmonary & Respiratory Sciences

Abstract

Introduction: Adequate aerobic capacity and muscle strength are essential elements to perform the activities that are required from professional soldiers & officers to optimize their peak performance & maintain physically demanding tasks. The newly recruited police officers will be subjected to 6_8 week's confinement in which they will have a training program including exercise & initial police training. The objective of this study was to assess the respiratory muscle power, blood pressure and hemoglobin during this period.

Method: This was a cross sectional study conducted during the period from July to September 2017 in Soba, faculty of police science and law, Khartoum, Sudan. Eighty-one policemen trainee were randomly selected, aged between 20 and 30 years underwent evaluation before & after the confinement period (40 days). Maximal respiratory pressure (MEP and MIP) was measured using respiratory pressure meter for respiratory muscle power. Hemoglobin, pulse & blood pressure was also measured.

Results: The mean values of MEP & MIP were significantly higher after the end of the confinement period (P>0.05). Also there was significant change in the mean of hemoglobin before & after the confinement period (p= 0.03). There was no change in pulse & blood pressures.

Conclusion: Police training confinement improves respiratory muscle power & hemoglobin level.

Keywords: Police training; Respiratory muscle power; Hb level in police training

Introduction

Exercise is a stressful situation that produces marked changes in body functions including the respiratory system. The physical inactivity is directly related to morbidity and mortality from many diseases [1]. Therefore, physical training is one of the major bases for good health and wellbeing and currently globally recommended [2]. During exercise the body's demand for oxygen increases as the breathing must also rise. This requires numerous muscles surrounding the lungs to contract in a highly coordinated manner. As the intensity of exercise increases, the respiratory muscles contract more forcefully and quickly to keep pace with the increase in oxygen demand. Training of the respiratory muscles increases their strength and improves lung function and was found to reduce the severity of obstructive sleep apnea in cervical spinal cord injury and improves breathing pattern in patients with COPD [3,4].

Maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP) are useful indices for assessment of respiratory muscles performance in adults as well as in children [5]. Several cross-sectional and cohort studies have shown significant improvement of lung function as a result of exercise in both children and adolescents [6-9]. However, measurement of respiratory muscles strength has not been widely investigated in relation to physical training. In this context, the present study aimed at assessing pulmonary function as well as respiratory muscles strength among policewomen trainees compared to healthy untrained sedentary group of medical students.

The common physiological changes that alter the body during exercise are the cardiopulmonary changes; mainly they include increase in pulmonary ventilation (breathing) which directly proportionate to the intensity & metabolic needs of exercise. Breathing may increase from typical resting rate of 15 breaths per min up to 40-50 breath per minute. As the intensity of exercise continue to increase a person reaches a maximum point above which oxygen consumption will not increase any more. This point is known as VO2 MAX and can be improved by long term endurance by increasing aerobic enzyme activity & improving glycogen stores in muscle.

A previous study was done by Awad et al. [10] 2012 on the effect of police training on some cardiopulmonary & hematological parameters in Khartoum state, Sudan. The aim of their study was to investigate the effect of training of male police officers on the spirometeric lung function test parameters, respiratory muscle power, blood pressure, hemoglobin & white blood cells. A cross sectional study conducted during the period from October to December 2012, in which 59 policemen trainee were randomly selected with another 30 medical students as control. The maximum inspiratory and expiratory pressure (MIP&MEP) were found to be significantly higher in police trainee MIP 106.9+28.17 cmH2O (P=0.005) and MEP 137.51+ 31.68 cmH2O (P=0.000) compared to control MIP 88.13+30.96 cmH2o and MEP 103.57+ 29.9 cmH2O. There was significant increase in Hb value, the mean of Hb in policemen was 14.5g/dl compared to control group 13.7g/dl.

Another study done by Segizbaeva MO et al. [11] on the effect of inspiratory muscle training on resistance to fatigue of respiratory muscles during exhaustive exercise. Daily inspiratory muscle strength training was performed for 3 weeks in 10 male subjects .the study found that inspiratory muscle training results in a significant increase in MIP (+18%) [11]. A study done by Branch Rasht, Islamic Azad University 2011 on the effect of one period of training on hemoglobin, hematocrit and RBCs of athlete girls. In which13 athlete girls were selected none randomly for 8 weeks of training .They found that there was significant decrease in HB after the period of training (P=0.045) [12]. Some of the studies suggest that in endurance- trained athletes hematological parameters such as hematocrit, hemoglobin concentration, and red blood cell (RBC) count are reduced, mainly due to exercise-induced plasma volume expansion, which sets in within a few days of exercise training [13]. One of the studies suggests that the physical training itself has no significant effect on hematological variables in athletes compared with controls. The specific type of duration of training is of major importance in adaptation of the RBC system and the iron metabolism [14].

Some of the studies performed to assess the influence of duration of training on hematological parameters among runners and compared them with age- and sex-matched controls group. They found that there is an increase in the counts of RBC and hemoglobin concentration in the runners compared to controls group [15-18]. The aim of this study was to investigate the effects of police training during confinement period on respiratory muscle power, blood pressure, pulse and hemoglobin.

Methods

A cross sectional descriptive study was conducted during July to September 2017 in the faculty of police sciences and law, Soba, Khartoum state, Sudan. Study population included 81 newly recruited subjects. The subjects were healthy with no symptoms of present illness aged between 20_30 years. Any subject with a history of cardiorespiratory diseases & acute respiratory infection were excluded from the study. The students were informed by consent to get sociodemographic data. Their weight was recorded without shoes on a weighing scale. Pulse was counted & blood pressure measured in a sitting position with a sphygmomanometer. Respiratory muscle power was measured by respiratory pressure meter (RPM), in measuring the maximum expiratory pressure (MEP) the subject was asked to inhale to the total lung capacity (TLC) & then exhale with as much effort as possible through the controlled leak of the meter for at least 3 seconds. The reading displayed was the maximum average expiratory pressure over 1 second. While the maximum inspiratory effort (MIP) was conducted by having the subjects expire to a residual volume (RV) & then perform a maximum inspiratory maneuver. The reading displayed was the maximum average inspiratory pressure over one second. Blood sample was collected into a container tube containing K3_EDTA (anticoagulant), and HB was measured using sysmex KX-21 automated hematology.

Results

The average age of the studied subjects was 25.5. The mean weight of participants was 85+ 7 Kg before training and 75+7 Kg after confinement period. The mean length of the participant was 180 +9 cm before and after confinement period. Our study found that the respiratory muscle powers measured by MIP & MEP were significantly increased after the confinement period (Table 1 & Figure 1). There was significant change in mean blood hemoglobin level before & after confinement as the meanHB level was found to be 11.75 g/dl before confinement period compared to 11.88 g/dl after i. There was no change in pulse & blood pressure. After the end of confinement period (The systolic mean pressure =117.4 mmHg) (diastolic mean pressure = 80.74mmHg) (pulse mean=84.74 beat/min).

Discussion

This study showed that the mean value of respiratory muscle power (MIP & MEP) were significantly higher after the end of confinement period MIP (p=0.001) & MEP (P=0.02) these finding did not differ much from the previous studies. A study done by Kamal et al. [10] and Segizbaeva et al. [11]. Our study showed that there was increase in hemoglobin level after the end of confinement period could be due to good nutritional status, or exercise induced hemo concentration as a result of fluid transfer from the blood to interstitial space. This differ from a previous study done by Islamic Azad University 2011 [12] suggested aerobic training decrease HB, HTC and RBCs in athlete. In our study there was no change in systolic & diastolic blood pressure after the end of confinement period. This differed from a study done by Kamal et al. [10] they found significant decrease in systolic blood pressure (P=0.001) and diastolic blood pressure (P=0.007) in policemen.

Conclusion

Physical training and exercise during the confinement period improved the pulmonary function and respiratory muscle power in police trainees after 40 days of training.

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