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Her unusual wheezing was getting worse. What was it?



One of the first things she noticed was that she had to constantly clear her throat. Everyone does it from time to time, but for her, a healthy woman in her 70s, it became a constant. The husband never complained. He was a surgeon, and when the throat clearing began, he showed her some breathing exercises. Sometimes it was helpful, but eventually she started whimpering again every few minutes. Even more annoying was that any effort could cause a strange, sharp wheeze. Even when she was on the phone, she often turned off the sound so that friends and family would not be worried.

Her doctor was not worried. Her lungs were clear; Oxygen saturation was ok. She visited a cardiologist who said that her heart was in good shape after a severe stress test.

Despite assurances, she noticed that it became easier to suffocate. In Europe with her granddaughter, she walked 20,000 steps a day on the mostly flat streets of Paris, but the rolling cobblestones of Montmartre made her huff and puff. She knew she had to find out. But when she returned to her home in Cupertino, California, Covid hit and everything shut down.

During this time, the stairs in her house became her measure. For decades, she climbed and descended these steps many times a day with no problem. She was used to the sharp wheezing that the stairs seemed to cause, but now that she had reached the top, her breath caught. She then had to stop halfway, and then after only a few steps.

Finally, as the pandemic subsided after a terrible year and a half, she turned to her GP and then to a team of specialists. Her lungs were clear and the chest x-ray was normal. Is it asthma or some kind of allergy? Various inhalers and antihistamines have proven ineffective; examination of her nose and throat with a microscope found nothing. The CT scan of her lungs was not completely normal: she had several small nodules, so seven months later she had another scan to see if any of the tiny dots had changed. They didn’t—probably just scars from some past infection. It was discouraging to hear that everything was fine, and at the same time to know that it was not.

The doctors didn’t know what else to do, and neither did the patient. her husband asked his colleagues. He called his old friend, the doctor. James Woolf in nearby San Jose. Wolfe was a pulmonologist and also an allergy specialist. Although antihistamines did not help, allergies may have played a role.

A few weeks later, the patient and her husband were in Wolfe’s office. While they were waiting for the specialist, the husband said to his wife, “Can you jump up and down a few times so the doctor can hear how you sound when you’re a little out of breath?”

It worked. While greeting his old friend, Wolfe noticed the patient’s noisy breathing. But it was obvious to him that this was not a typical wheeze. They usually occur during exhalation. This woman’s breathing was the noisiest when she inhaled, a type of wheezing known as stridor. This is an important observation because the causes of stridor are different from other types of wheezing. Stridor is usually caused by blockage of the upper airways due to dysfunction of the vocal cords or swelling of tissues in the nose or throat. It was puzzling; her upper respiratory tract had already been examined. They were fine.

Wolfe asked the patient for a second breath test when she arrived. The first one, made a year earlier, was perfectly normal. This one wasn’t. The changes were small, but real. The amount of air she could force out was less than during testing a year earlier.

Maybe it’s some kind of severe form of asthma, given that conventional medications didn’t help? Or is it some slow growing lung infection? There is a bacterium distantly related to tuberculosis called the Mycobacterium avium complex (MAC) that can cause coughing, shortness of breath, and sputum production. Rare, but most common in older women. This is believed to be caused, at least in part, by the woman’s reluctance to cough and clear mucus and other secretions from her lungs and airways. It’s called Lady Windermere Syndrome, after a character in an Oscar Wilde play. Lady Windermere is a very decent young woman from the Victorian era who was apparently too well-behaved to cough or show other signs of illness. Nodules in the patient’s lungs, which were found on a CT scan, could be the earliest sign of such an infection.

Wolfe commissioned a series of tests to identify each of these disorders. He also ordered another CT scan of her lungs – her third – to see if the nodes had changed in the months since her last scan.

Dr. Emily Tsai, a radiologist specializing in chest imaging at Stanford University School of Medicine, sat in a darkened room reviewing more than 300 images of a patient’s new CT scan. While you could view each image individually, it’s often more useful to view them sequentially, like a flipbook that turns drawings into moving pictures. In this way, the radiologist can take a 3D tour of the chest being examined, following the blood vessels and airways as they appear, advance, and complete in this animated show.

Tsai developed her own system: first, she looked at the whole image, looking for obvious deviations and getting a general idea. She compared the newest views with earlier images. She then focused on the part of the lung where abnormalities were found or expected. In this woman’s case, she looked to see where the reported nodes were located. Small scars remain where the narrow treelike branches of the airways have stretched and become baggy, which is called bronchiectasis. This can certainly be accompanied by a diagnosis of MAC infection. Then she once again carefully examined all the other parts of the chest. With such images filled with so much information, the radiologist must examine the images as closely as possible. Nobody can see everything. Maybe artificial intelligence will get there someday. But she tried to see what was there.

When she scrolled all the way to the top of the image, she saw something that seemed a little crazy. The trachea, the breathing tube that connects the upper airways of the nose and mouth to the lower airways of the lungs, seemed oddly narrow at the top. The constriction was less than a centimeter long before it expanded to a normal diameter. Tsai found the same narrowing on other CT scans and reviewed the reports to see what previous radiologists had made of this discovery. None of them mentioned it at all, perhaps because it looked like a tiny puddle of discharge. The bottom line is that in all three exams everything was the same. Secretions move. This narrowing, whatever the cause, did not occur. Tsai wasn’t sure what to do about it, but she suggested in her report that it might be contributing to the patient’s symptoms.

When Wolfe saw the radiologist’s report, he realized that this narrowing of the trachea could be the cause of all of the patient’s symptoms. How did it happen? She never needed to have a breathing tube placed in her trachea during surgery or serious illness—that was the most common reason for this unusual result. Wolfe ordered additional tests to look for possible infections or inflammatory causes of the narrowing. Everyone was incomprehensible. It wasn’t the MAC or any other reason Wolfe could come up with or verify. Ruling everything out, he gave him her diagnosis: she had idiopathic subglottic stenosis. Idiopathic means the cause is unknown. The infraglottic identified location in the trachea, just below the vocal cords. This rare and little-studied disease occurs almost exclusively in middle-aged women. Because her constriction was causing her to become short of breath, the stricture had to be opened.

Wolfe sent her to a surgeon, who used a balloon to widen the narrowed tract. The patient told me that she felt the difference as soon as she woke up, and eight months after the operation she regained everything she had lost. A few days later she was able to run up and down the stairs in the hallway again.

Lisa Sanders, MD, is the journal’s contributor. Her latest book is Diagnosis: Solving the Most Baffling Medical Mysteries. If you decide to share your case, write here at

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Hugh Jackman May Have Skin Cancer and Takes the Opportunity to Remind People to Use Sunscreen



This isn’t the first time Jackman has reminded people to use sunscreen in an Instagram post. Jackman reveals he has basal cell carcinoma on his nose, adding, “Test yourself. AND USE sunscreen!!!”

In a similar way, Khloe Kardashian recently had two biopsies after noticing a small bump on her cheek that didn’t go away by wearing a bandage while it healed. However, unlike Jackman, Kardashian had a history of melanoma, the most serious form of skin cancer. At 19, she was diagnosed and treated for melanoma on her back.

Around 80% of skin cancers are basal cell carcinoma.affecting close to 1 in 5 americans. This condition is easily treatable and less likely than other types of cancer to spread to other parts of the body.

We asked dermatologists about the early warning signs of basal cell carcinoma, risk factors, prevention and treatment, including the importance of using sunscreen and getting screened for skin cancer.

Here are the early warning signs

Basal cell carcinoma occurs due to a combination of genetic and environmental factors. Chronic exposure to UV rays from the sun is the biggest risk factor, especially in early childhood and adolescence.

“All this happened 25 years ago. It’s coming out now. Apply some sunscreen. You will still have an incredible time there. Fine. Please take care of yourself,” Jackman concluded the video.

Other risk factors include indoor tanning, history of skin cancer, age over 50, fair skin, chronic infections, and skin inflammation, including burns and scars.

Hadley King, a board-certified dermatologist in New York, told BuzzFeed News that there is no such thing as a healthy tan, even if you don’t have sunburn.

“Sunburn is a defense mechanism that kicks in when the DNA of skin cells is damaged by ultraviolet radiation,” King said. “Both sunburn and sunburn are the result of DNA damage that can pave the way for skin cancer.”

Basal cell carcinoma most commonly occurs in parts of the body that are most frequently exposed to the sun, including face, neck and hands. However, symptoms can vary from person to person and the type of skin cancer.

Basal cell carcinoma may appear as a shiny bump that may be red, white, or clear, black, or brown in people with darker skin tones an ulcer filled with fluid that oozes, crusts, or bleeds; a shiny or flaky patch of skin that looks like scar tissue or even one that has pigmented areas or dark patches that look blue or gray in color and could be mistaken for melanoma.

Unlike other skin blemishes or ulcers, skin cancer doesn’t heal, Elizabeth Geddes-Bruce, a board-certified dermatologist at Westlake Dermatology in Austin, told BuzzFeed News. “They can be itchy or painful, pink or brown,” she said. “Basal cell carcinoma often tends to be light pink or clear and may bleed.”

If left untreated, there is a chance that basal cell carcinoma can spread to other parts of the body. However, this type of skin cancer rarely spreads. Common treatment options include various types of surgery, such as curettage or scraping to remove a skin tumor. People rarely need radiation therapy or chemotherapy for basal cell carcinoma.

Importance of SPF

Since wearing sunscreen can reduce skin damage and skin cancer, finding a product that will protect your skin even on non-sunny days can be helpful for prevention.

“It’s very important to practice sun protection every day and I think this is often overlooked because people think it’s only important on particularly sunny days and they’ll be spending a significant amount of time in the sun,” King. said. “Some people think that the products are unpleasant to use – they will smell like coconuts or look like white paste. The good news is that there are great, sleek products available these days that are very easy to integrate into your daily routine.”

The FDA recommends using broad spectrum sunscreen with included SPF 15 or higher on all exposed skinespecially the nose, ears, neck, hands, feet and lips. The highest SPF over 50 protects against UV radiation.

It’s also important to reapply sunscreen every two hours after swimming or sweating, leaving it on for 30 minutes.

In addition, protective clothing Sunglassesand staying in the shade can protect against the sun’s UVA and UVB rays, in addition to avoid tanning beds.

Skin cancer screening can save lives

According to the Skin Cancer Foundation, you should get a full screening for skin cancer at least once a year, and more often if you have risk factors.

If a suspicious lesion is found, the doctor may perform a biopsy in several ways:

“Skin cancer screening absolutely saves lives,” Geddes-Bruce said. “We often do not spend enough time studying our body and do not notice a changing or suspicious spot. A certified dermatologist can do this for you and detect skin cancer or precancerous conditions early, while they are still easily treatable.”

In between skin cancer screenings, King recommends monthly head-to-toe self-exams for any suspicious lesions.

“I recommend doing it completely naked, in front of a full-length mirror, with a hand mirror in a well-lit area,” King said. “It is extremely important to know your skin very well so that you can recognize if there are spots that are new or changing. Some dermatologists recommend doing this on your birthday and every month on that day to help you remember to check your birthday suit on your birthday.”

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Genetic Obesity Less Harmful to the Heart?



When it comes to the adverse effects of obesity on the heart, it’s less about nature and more about food, according to a double study out of Sweden.

In an analysis of nearly all twins in the country, obesity predicted cardiovascular disease (CVD) risk across the board in every genetic risk group, reported Ida Karlsson, PhD, from the Karolinska Institute in Stockholm, and her colleagues at electronic clinical medicine.

However, midlife obesity, despite having a low polygenic risk score suggesting a greater role for environmental and lifestyle factors than genetics for that individual, was a stronger predictor of CVD than obesity combined with a high polygenic risk score. . HR 2.08 vs 1.55).

“While one should always strive for a healthy lifestyle, the results of the current study and previous work suggest that environmentally induced obesity may be more harmful than genetically induced obesity,” the group concluded.

More complete control of confounding by observing only identical twins in the cohort erased the difference in association between obesity and categorical polygenic risk scores.

“Importantly, this indicates that the negative health effects of obesity may be influenced by factors other than obesity itself, because otherwise we would expect similar effects of obesity, whether predicted by genetic predisposition or environmental factors. suggested Karlsson and his colleagues.

They noted that this is not an isolated finding, pointing to the heterogeneity of genetic versus environmental obesity for important outcomes, including dementia and mortality, in the US data.

The study included data from additional studies of the Swedish Twin Registry, a population-based registry of virtually all twins born in the country. The analysis included 15,786 Swedish twins born before 1959 who had a BMI measured at age 40-64, and 5488 twins with a BMI measured at age 65 or later (3286 were in both groups). CVD was determined from prospective data in linked national health registries and cause-of-death registries up to 2016, with a median of 18 years of follow-up.

In all included additional registry studies (conducted between 1984 and 2010), genotyping was available to obtain an individual polygenic estimate of BMI. This risk estimate was derived from the most recent genome-wide association study of BMI, which identified 941 genetic variants significantly associated with BMI, which together explained 6-14% of the trait variance.

Each standard deviation with a higher polygenic risk score was associated with a higher BMI of 1.23 (95% CI 1.07–1.18) units at middle age and 1.16 (95% CI 1.07–1. 26) units of higher BMI in old age, adjusted for sex and age when BMI is measured. Adjusting for smoking and education did not affect the scores. CVD risk was 14% lower among obese people when the polygenic risk score was increased by one standard deviation from the mean.

“The results were similar when obesity was measured in old age but suffered from low power,” Carlsson and his team noted, although they acknowledged that “the causes and consequences of being overweight or obese in old age are more complex, with evidence inversely. with … mortality.

To identify genetic factors not covered by these variants in the polygenic risk scale, the researchers also looked at pairs of twins: 3124 fraternal and 2020 identical twins with BMI estimated at middle age. Of these, 769 and 443 couples were discordant in terms of CVD status, respectively.

“Because twins share DNA (to varying degrees), in both fetal and early childhood environments, the twin control circuit elegantly controls this mixing,” the researchers write. Previous twin studies have estimated the heritability of BMI at 45-85%.

Associations were blunted in these analyses. The hazard ratio of obesity to cardiovascular risk was 1.14 (95% CI 0.64–2.02) for identical twin pairs and 1.64 (95% CI 1.11–2.42) for fraternal twin pairs. .

When identical pairs of twins were sorted into polygenic risk groups, there was no difference in the association of cardiovascular disease and obesity between genetically predictable low and high BMIs (RR 1.21 and 1.29, respectively).

“If effect estimates remain stable in twin pairs (especially in monozygotic twin pairs that share the same DNA), this indicates, but is not proof of, a causal relationship,” Karlsson and his team noted. “In contrast, if the effect estimate is close to zero in pairs of twins, this is strong evidence against causation, as it indicates that the association is due to genetic or other familial factors.”

Limitations of the study included reliance on some self-measured height and weight data in the analysis to calculate BMI, with the possibility of some misclassification that could bias the results towards zero if they were non-differential with respect to the outcome. In addition, there were no primary care data in the registries, which would preclude finding an association with milder CVD.

“While we all know that it takes more than just exercise and diet to fight obesity, there is still a lot of stigma associated with it,” Karlsson said in a statement. “I think a lot could be gained by focusing on what caused obesity and what we can do to reduce the risk of comorbidities in each person, instead of focusing mainly on BMI.”

Information disclosure

The study was funded by the Karolinska Institute’s Strategic Epidemiology Research Program; Lou and Hans Osterman Foundation; Foundation for Geriatric Diseases of Karolinska Institute; Swedish Research Council for Health, Work Life and Welfare; Swedish Research Council; and the National Institutes of Health.

Carlsson announced payments to her institution from the Karolinska Institute Research Foundation and Eurolife, as well as an award from the Northern Gerontological Federation.

main source

electronic clinical medicine

Link to source: Ojalehto, E. et al. Genetically and environmentally predictable obesity in association with cardiovascular disease: a nationwide cohort study eClinicalMedicine 2023; DOI: 10.1016/j.eclinm.2023.101943.

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The Social Security Fund is projected to be depleted earlier than expected



The trustees who oversee the Social Security and Medicare trust funds have released new forecasts that describe the financial health of these programs and how long they should cover benefits to beneficiaries.

The Social Security trust funds, which together include benefits paid to retirees and their wage earners and benefits paid to disabled workers, are expected to run out in 2034, a year earlier than previously thought, according to a report released on Friday.

The report cites “significant funding problems” for the deficit. Social Security has been operating at a loss since 2010, but the financial picture has worsened in recent years. A key indicator of this is the ongoing wave of retirement among baby boomers, which is projected to grow faster than the number of insured workers who pay into the Social Security fund through their income taxes.

“The Trustees recommend that legislators address the projected trust fund shortfall in a timely manner to gradually make the necessary changes and give workers and beneficiaries time to adjust,” their report says.

Prospects for Medicare Trust Fund Improve

On the other hand, Medicare’s main reserve, the hospital insurance trust fund, is expected to cover 100% of beneficiaries for three years longer than previously expected. This is due to an increase in the number of insured workers who contribute to the fund through taxes deducted from their paychecks and higher projected wages.

In addition, renewed health spending expectations in the wake of the Covid-19 pandemic and the ability to negotiate prescription drug prices are positively impacting Medicare trust fund reserves.

Despite this, the Medicare trustees say the fund “still faces a significant financial gap that will need to be addressed through further legislation.”

The Biden administration is trying to push a $6.8 trillion budget. In it, hey offers raising taxes on higher-paid Americans to cover the projected shortfall.

“Social Security and Medicare are the two main programs that old Americans[s] rely on your pensions,” Treasury Secretary Janet Yellen said in a statement.

“The Biden-Harris administration is committed to ensuring the long-term viability of these critical programs so that retirees can receive the hard-earned benefits they are entitled to,” she said.

Julie Zirkin contributed.

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