A MAN who died of brain cancer was misdiagnosed with anxiety and told to "breathe into a paper bag" to ease his symptoms.

Keith Evans was 21 when he collapsed during a suspected panic attack.

Keith Evans shortly before he died of brain cancer


Keith Evans shortly before he died of brain cancerCredit: SWNS
Dad Keith, who was misdiagnosed with anxiety, with his little boy Joel


Dad Keith, who was misdiagnosed with anxiety, with his little boy JoelCredit: SWNS

He then developed painful headaches and was given tools to manage his anxiety.

Weeks later during a visit to his GP, he was referred for an MRI scan where he was diagnosed with a glioblastoma - a fast-growing and aggressive brain tumour.

Despite being given six months to live, Keith survived five and a half years. He died aged 27.

Keith's mum, Lorraine, from Bulkington, Warwickshire, said: "We felt like paranoid parents.

"Although at the time he was interviewing for a new job, we thought this could have caused some unrest, but being told he was having panic attacks seemed odd.

"After multiple occasions where we called 999 we were told the same thing and Keith was given ways to manage his anxiety, including breathing into a paper bag."

Throughout his cancer battle, he raised tens of thousands of pounds for charity while undergoing radiotherapy and chemotherapy treatment.

Lorraine added: "Keith wanted to be one of the five per cent of GBM patients who survive more than five years.

"He made dramatic changes to his lifestyle and took up cycling as he was no longer allowed to drive.

"He made a name for himself within the cycling community.

"A favourite event which came about inspired by his journey was called Ride on Keith.

"He got to take part in the event before coming off his bike due to a seizure in 2015.

"Soon his mobility deteriorated, and a scan showed the tumour had returned."

This weekend, dozens of cyclists are expected to take part in the final bike ride in memory of the father-of-one, who died of brain cancer in October 2015, raising funds for Brain Tumour Research.

The 'Ride on Keith' event, which has raised more than £7,500 since its inception, will take place on June 10.

Among the riders will be Keith's widow, Harriet Evans, and their son, 10-year-old Joel, who was just one when Keith died.

The 25-, 55- and five-mile child-friendly cycle ride will set off from Makins Fishery on Bazzard Road at 8.30am.

We felt like paranoid parents.

LorraineKeith's mum

Lorraine said: "For over a decade, we've helped to raise the profile of brain tumours and worked towards driving more funding to find a cure for the disease, with Keith at the helm of the events when he was alive.

"He achieved so much in the five and a half-years he survived, including cycling 275 miles from London to Paris and covering the 1,000-mile route from Land's End to John O'Groats over a 10-day period - all during treatment.

"Since his death, the event has been a fantastic way to remember him and this year we hope to create lasting memories while raising money for Brain Tumour Research.

"Although this is the last event of its kind, we will continue to work with the charity to raise awareness for more research into the disease."

One in three people know someone affected by a brain tumour.

They kill more children and adults under the age of 40 than any other cancer, yet just one per cent of the national spend on cancer research has been allocated to brain tumours since records began in 2002.

Mel Tiley, community development manager at Brain Tumour Research, said: "We're grateful to Keith's family for sharing his story.

"It's wonderful to hear of everything Keith achieved after receiving a shocking diagnosis.

My daughter applied for a job at our local chippy - I was outraged by the response
I wear underwear as outerwear - women hate it, it's not my fault their men stare

"His story reminds us that brain tumours are indiscriminate, and they can affect anyone and any age.

"If we are to understand the complexity of each diagnosis, we need more funding to research the disease."

Keen cyclist Keith inspired a decade of charity fundraising


Keen cyclist Keith inspired a decade of charity fundraisingCredit: SWNS
The final 'Ride on Keith' event will take place on June 10


The final 'Ride on Keith' event will take place on June 10Credit: SWNS
Keith and his family, including mum Lorraine


Keith and his family, including mum LorraineCredit: SWNS

What is glioblastoma and what are the symptoms?

A MALIGNANT brain tumour is a cancerous growth in the brain.

Common symptoms include:

  • headaches (often worse in the morning and when coughing or straining)
  • fits (seizures)
  • regularly feeling sick (vomiting)
  • memory problems or changes in personality
  • weakness, vision problems or speech problems that get worse

There are lots of types of brain tumour. They have different names depending on where they are in the brain.

They're also given a number from 1 to 4, known as the grade.

The higher the number, the more serious a tumour is:

  • grade 1 and 2 brain tumours are non-cancerous (benign) tumours that tend to grow quite slowly
  • grade 3 and 4 brain tumours are cancerous (malignant) tumours that grow more quickly and are more difficult to treat

Glioblastomas are grade 4 and are the most common high grade brain tumour in adults.

They grow quickly, are likely to spread and often come back even after being treated.

The main treatments are surgery, radiotherapy, chemotherapy, radiosurgery and carmustine implants.

Source: NHS

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An 18-month-old toddler from Bengaluru was recently treated for a rare, aggressive brain tumour in a city hospital.  

The child was diagnosed with atypical teratoid rhabdoid tumour (ATRT) last year and was operated on at another hospital. The child was brought to MGM Healthcare in the city last month and investigations revealed that the tumour recurred in the brain stem.  

ATRT is a rare and fast-growing cancerous tumour of the brain, with half of them beginning in the cerebellum or brain stem, which controls breathing, heart rate and the muscles used for seeing, hearing, walking, talking and eating.  It occurs in fewer than 10% of children with brain tumours and is often seen in children aged below three. It can occur in older children and adults as well. 

Neurosurgery director Roopesh Kumar and his team operated on the child for four-and-a-half hours. As an intra-operative MRI revealed residual lesion, another three-hour procedure was done the next day to remove the tumour. 

Dr. Kumar said ATRT commonly presents as a brain tumour but can occur anywhere in the nervous system, including the spinal cord. “The surgery proved to be challenging for our team as it involved multiple compartments of the brain and the fact that this child had undergone surgery elsewhere last year,” he said.  

While the first surgery took around four-and-a-half hours in the evening, the second surgery was done the next morning and took three hours, he said. The child was discharged five days later and was doing well, Dr. Kumar said.  

A 58-year-old woman from a north-eastern State, who had a similar cancer, was treated at the hospital. She had developed brain stem tumour five years ago but recently she began to feel weak and soon became wheelchair-bound. Normally, such tumours were treated using chemotherapy and radiation but Dr. Kumar decided to remove the tumour that helped the patient recover faster. She began walking within three days of the surgery, he added.  

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MEMPHIS, Tenn., June 8, 2023 /PRNewswire/ -- Methodist Le Bonheur Healthcare will begin offering free blood pressure screenings in partnership with Concorde Career College, Remington College and local north Memphis barbershops. 

On select days at participating barbershop locations, trained students from Concorde Career College and Remington College will conduct blood pressure checks for those coming in for haircuts. Individuals who screen above or below normal range will be encouraged to follow up with their medical provider. In addition, educational material provided by the American Heart Association will be available on heart disease prevention and treatment.

Upcoming dates include the following:

  • June 17 and June 24
    10 a.m. – 12 p.m.
    Riley's Cutz located at 2733 Bartlett Blvd. in Bartlett, Tenn.
  • June 30
    2 p.m. – 4 p.m.
    Heavy Weight Cutz & Styles located at 3209 Coleman Road in Memphis, Tenn.

According to the Memphis-based healthcare system in their 2022 Community Needs Health Assessment, heart disease ranked as the number one leading cause of death in both DeSoto County, Miss., and Shelby County, Tenn.

A person's blood pressure changes throughout the day depending on physical activity, nutrition and other lifestyle choices. High blood pressure, also known as hypertension, typically develops over time and results in a decreased supply of blood and oxygen reaching the heart.

Symptoms of high blood pressure can include severe headaches, chest pain, dizziness, shortness of breath or trouble breathing, blurred vision, nausea and vomiting. Risk factors for developing hypertension increase with age, being overweight or obese, consuming a high-salt diet and physical inactivity.

Yearly blood pressure screenings are recommended for adults age 18 and older.

About Methodist Le Bonheur Healthcare

Based in Memphis, Tennessee, Methodist Le Bonheur Healthcare has been caring for patients and families regardless of their ability to pay for more than 100 years. Guided by roots in the United Methodist Church and founded in 1918 to help meet the growing need for quality healthcare in the greater Memphis area, MLH has grown from one hospital into a comprehensive healthcare system with 13,000 Associates supporting six hospitals, including nationally ranked Le Bonheur Children's Hospital, ambulatory surgery centers, outpatient facilities, hospice residence and physician and specialty practices serving communities across the Mid-South. From transplants and advanced heart procedures to expert neurology services and compassionate cancer care, MLH offers clinical expertise with a focus on improving every life we touch.

SOURCE Methodist Le Bonheur Healthcare

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<p><a href=”https://www.nydailynews.com/news/national/ny-new-york-air-quality-canadian-fire-20230606-2s24wadx4rh2lakruxzhmmywnm-story.html” target=”_blank” rel=”noopener”>Smoke that’s been blown</a> southward from hundreds of Canadian <a href=”https://www.cbc.ca/news/canada/montreal/quebec-fires-burning-out-of-control-1.6865147″ target=”_blank” rel=”noopener”>wildfires</a> are <a href=”https://www.bostonherald.com/2023/06/07/canadian-wildfires-photos-smoke-us/”>causing hazardous air-quality conditions across the eastern United States</a>. With all the nasty air particles floating around, experts say you should wear a mask if you do venture out.</p><p class=”default__StyledText-sc-1wxyvyl-0 hnShxL body-paragraph”>Just like with the coronavirus, the stronger the mask, the better, although any face covering is better than none, <a href=”https://www.nydailynews.com/new-york/ny-hazardous-air-quality-nyc-canadian-wildfires-need-to-know-20230607-qw7juholebgsdbc2hrfec7ox34-story.html”>said Ramón Tallaj, a doctor who leads SOMOS Community Care,</a> a nonprofit health network based in New York.</p><p><img class=”size-article_inline lazyautosizes lazyload” src=”https://i0.wp.com/www.bostonherald.com/wp-content/uploads/2023/06/GettyImages-1258511415.jpg?fit=620%2C9999px&amp;ssl=1″ sizes=”491px” srcset=”https://i0.wp.com/www.bostonherald.com/wp-content/uploads/2023/06/GettyImages-1258511415.jpg?fit=620%2C9999px&amp;ssl=1 620w,i0.wp.com/www.bostonherald.com/wp-content/uploads/2023/06/GettyImages-1258511415.jpg?fit=780%2C9999px&amp;ssl=1 780w,i0.wp.com/www.bostonherald.com/wp-content/uploads/2023/06/GettyImages-1258511415.jpg?fit=810%2C9999px&amp;ssl=1 810w,i0.wp.com/www.bostonherald.com/wp-content/uploads/2023/06/GettyImages-1258511415.jpg?fit=1280%2C9999px&amp;ssl=1 1280w,i0.wp.com/www.bostonherald.com/wp-content/uploads/2023/06/GettyImages-1258511415.jpg?fit=1860%2C9999px&amp;ssl=1 1860w” alt=”Smoke From Canadian Wildfires Blows South Creating Hazy Conditions On Large Swath Of Eastern U.S.” width=”1024″ data-sizes=”auto” data-src=”https://i0.wp.com/www.bostonherald.com/wp-content/uploads/2023/06/GettyImages-1258511415.jpg?fit=620%2C9999px&amp;ssl=1″ data-attachment-id=”3086349″ data-srcset=”https://i0.wp.com/www.bostonherald.com/wp-content/uploads/2023/06/GettyImages-1258511415.jpg?fit=620%2C9999px&amp;ssl=1 620w,i0.wp.com/www.bostonherald.com/wp-content/uploads/2023/06/GettyImages-1258511415.jpg?fit=780%2C9999px&amp;ssl=1 780w,i0.wp.com/www.bostonherald.com/wp-content/uploads/2023/06/GettyImages-1258511415.jpg?fit=810%2C9999px&amp;ssl=1 810w,i0.wp.com/www.bostonherald.com/wp-content/uploads/2023/06/GettyImages-1258511415.jpg?fit=1280%2C9999px&amp;ssl=1 1280w,i0.wp.com/www.bostonherald.com/wp-content/uploads/2023/06/GettyImages-1258511415.jpg?fit=1860%2C9999px&amp;ssl=1 1860w” /> People wear masks as they wait for the tramway to Roosevelt Island as smoke from Canadian wildfires casts a haze over the area on June 7, 2023 in New York City. Air pollution alerts were issued across the United States due to smoke from wildfires that have been burning in Canada for weeks. (Photo by Eduardo Munoz Alvarez/Getty Images)</p><p>Dr. Jennifer Logan, a pediatric pulmonologist with Lehigh Valley Health Network in Pennsylvania, <a href=”https://www.mcall.com/2023/06/07/red-alert-wildfires-health-risks-lehigh-valley/”>told The Morning Call</a> that wearing most masks will not help protect against smoke inhalation and the small particulates in the smoke can even collect in the masks, meaning that wearing a cloth, surgical or low-quality filtration mask may actually be counterproductive.</p><p>However, Chrysan Cronin, director of public health at Muhlenberg College in Allentown, Pennsylvania, said for people who have to spend extended amounts of time outdoors for work or some other reason, a N95 mask can be effective, as it can filter out extremely small particles.</p><p><a href=”https://www.nymetroweather.com/” target=”_blank” rel=”noopener”>Meteorologist John Homenuk</a> also said N95 masks are “going to filter out these particles most effectively.”</p><p>“If you still have an N95 mask or you want to go grab one, it’s recommended to wear them because they do filter the harmful particles out, at least to some degree,” <a href=”https://www.nymetroweather.com/” target=”_blank” rel=”noopener”>Homenuk</a> told the New York Daily News.</p><p class=”default__StyledText-sc-1wxyvyl-0 hnShxL body-paragraph”>Tallaj did have a tip for those who may only have surgical masks on hand: Flip the mask so that the smoother, blue side is on the inside, near your mouth.</p><p class=”default__StyledText-sc-1wxyvyl-0 hnShxL body-paragraph”>“Surgeons use it with the blue part outside, because they don’t want their mouth and their breathing to go inside the patients during surgery,” Tallaj said. “In this case, it’s the other way around. You don’t want the [particles] to come to you.”</p><h4 class=”header__StyledHeading-sc-30ohha-0 fjSHlS”>Is this smoke just uncomfortable or dangerous?</h4><p class=”default__StyledText-sc-1wxyvyl-0 hnShxL body-paragraph”>Both.</p><p>Logan <a href=”https://www.mcall.com/2023/06/07/red-alert-wildfires-health-risks-lehigh-valley/”>told The Morning Call</a> that for children, the elderly and those with respiratory conditions like asthma, chronic obstructive pulmonary disease and cystic fibrosis, the small particulates in the smoke can be particularly harmful. But she added everyone should try to minimize their exposure to the smoke.</p><p><img class=”size-article_inline lazyautosizes lazyload” src=”https://i0.wp.com/www.bostonherald.com/wp-content/uploads/2023/06/TMC-L-CanadaWildfires.webp?fit=620%2C9999px&amp;ssl=1″ sizes=”491px” srcset=”https://i0.wp.com/www.bostonherald.com/wp-content/uploads/2023/06/TMC-L-CanadaWildfires.webp?fit=620%2C9999px&amp;ssl=1 620w,i0.wp.com/www.bostonherald.com/wp-content/uploads/2023/06/TMC-L-CanadaWildfires.webp?fit=780%2C9999px&amp;ssl=1 780w,i0.wp.com/www.bostonherald.com/wp-content/uploads/2023/06/TMC-L-CanadaWildfires.webp?fit=810%2C9999px&amp;ssl=1 810w,i0.wp.com/www.bostonherald.com/wp-content/uploads/2023/06/TMC-L-CanadaWildfires.webp?fit=1280%2C9999px&amp;ssl=1 1280w,i0.wp.com/www.bostonherald.com/wp-content/uploads/2023/06/TMC-L-CanadaWildfires.webp?fit=1860%2C9999px&amp;ssl=1 1860w” alt=”Smoke from wildfires in Canada affect the Lehigh Valley for a second day Wednesday, June 7, 2023, as seen at Easton Avenue in Bethlehem. (April Gamiz/The Morning Call)” width=”2751″ data-sizes=”auto” data-src=”https://i0.wp.com/www.bostonherald.com/wp-content/uploads/2023/06/TMC-L-CanadaWildfires.webp?fit=620%2C9999px&amp;ssl=1″ data-attachment-id=”3086358″ data-srcset=”https://i0.wp.com/www.bostonherald.com/wp-content/uploads/2023/06/TMC-L-CanadaWildfires.webp?fit=620%2C9999px&amp;ssl=1 620w,i0.wp.com/www.bostonherald.com/wp-content/uploads/2023/06/TMC-L-CanadaWildfires.webp?fit=780%2C9999px&amp;ssl=1 780w,i0.wp.com/www.bostonherald.com/wp-content/uploads/2023/06/TMC-L-CanadaWildfires.webp?fit=810%2C9999px&amp;ssl=1 810w,i0.wp.com/www.bostonherald.com/wp-content/uploads/2023/06/TMC-L-CanadaWildfires.webp?fit=1280%2C9999px&amp;ssl=1 1280w,i0.wp.com/www.bostonherald.com/wp-content/uploads/2023/06/TMC-L-CanadaWildfires.webp?fit=1860%2C9999px&amp;ssl=1 1860w” /> Smoke from wildfires in Canada affect the Lehigh Valley for a second day Wednesday, June 7, 2023, as seen at Easton Avenue in Bethlehem. (April Gamiz/The Morning Call)</p><p>She said the particulate matter in the smoke is very small and can easily work its way into the smallest airways of the lungs, which can cause coughing and wheezing, particularly in people with chronic respiratory conditions.</p><p>However, even for healthy people, prolonged exposure can cause short-term problems like eye irritation, pulmonary inflammation and issues with lung function, according to the U.S. Environmental Protection Agency.</p><p>Dr. Douglas Corwin, a critical care physician specializing in pulmonary disease with St. Luke’s University Health Network based in Pennsylvania, said for most people, short-term exposure should cause nothing more than temporary annoyance or mild discomfort.</p><p>“The smell can be irritating, annoying or it can be a little frankly nauseating, but in terms of long-term health repercussions this short burst shouldn’t cause any permanent damage,” Corwin said.</p><h4 class=”header__StyledHeading-sc-30ohha-0 fjSHlS”>Should I even go outside?</h4><p class=”default__StyledText-sc-1wxyvyl-0 hnShxL body-paragraph”>Young people, older adults and people with underlying health issues <a href=”https://www.weather.gov/okx/” target=”_blank” rel=”noopener”>should stay indoors</a> and keep their windows shut. All others should also limit their <a href=”https://www.iqair.com/us/air-quality-map/usa/new-york/new-york-city” target=”_blank” rel=”noopener”>exposure to the outdoors</a> and take precautions.</p><p class=”default__StyledText-sc-1wxyvyl-0 hnShxL body-paragraph”>“The main thing is to limit outdoor exposure and obviously any strenuous activity. You don’t want to be gasping for air and breathing this stuff in all day, if you can avoid it,” <a href=”https://www.nymetroweather.com/” target=”_blank” rel=”noopener”>Homenuk</a> <a href=”https://www.nydailynews.com/new-york/ny-hazardous-air-quality-nyc-canadian-wildfires-need-to-know-20230607-qw7juholebgsdbc2hrfec7ox34-story.html”>told the Daily News</a>.</p><p>Parents should limit outdoor play for their children, Logan said. “Children breathe faster and when you’re exercising you breathe in much deeper and faster so you will inhale more particulate matter if you are exercising outside,” Logan said.</p><p>Corwin said that those with respiratory issues or parents of children with respiratory issues should follow existing action plans set out by their physicians or should contact their doctors if they need extra guidance. Logan said everyone should stay inside when possible, keep windows closed and make sure their air filters are clean.</p><p>“If you can smell the smoke, you’re probably breathing in the particulate matter,” Logan said. “If you’re not smelling it, you’re probably in the clear.”</p><h4>Are there effects of repeated smoke inhalation?</h4><p>Research into the effects of repeated short-term exposure to wildfire smoke is limited. Studies have shown reduced and worsening lung function in firefighters exposed to heavy smoke while fighting wildfires, according to the EPA. Some studies have shown also <a href=”https://www.sciencedirect.com/science/article/pii/S2667278221001073#sec0017″>correlations with wildfire smoke exposure and increases in general mortality, respiratory illness and cancer</a>.</p><p>However, wildfires and wildfire smoke exposure has been shown to cause respiratory issues leading to increased emergency room visits and hospital admissions for respiratory illness in affected areas. Corwin said this is why both people with chronic respiratory illness and healthy people should be careful.</p><p>“Be smart about it. If you don’t need to be outside training for a marathon, for the next couple of days maybe this is the time to be inside in the gym, where there’s kind of purified or filtered air via air conditioning,” Corwin said. “Hopefully this is a relatively transient event. It should be hopefully clearing out the next 24 to 48 hours — if activities can be delayed, they should.”</p><p><em>Contributing: Leif Greiss, The Morning Call; Josephine Stratman and Chris Sommerfeldt, New York Daily News</em></p>

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Your everyday life and general well-being may be negatively impacted by upper back pain, which may be a severe illness. 

Understanding the underlying reasons for your discomfort – a gradual ache or a severe shooting pain – is essential to finding relief. 

In this post, we will examine the seven most typical causes of upper back pain, giving you helpful information to help you recognize and address the root reasons. 

You will be better prepared to appropriately treat your upper back discomfort if you understand these reasons better.

7 common causes of upper back pain

1. Poor posture

Do you frequently catch yourself slumping over your work or slouching in your chair?

Poor posture is one of the main causes of upper back discomfort. Chronic discomfort can result from slumping or sitting in positions that put undue strain on the muscles and ligaments in your upper back [1]. 

The muscles in your upper back weaken and stretch out when you have bad posture, which causes pain and strain.

Make a deliberate effort to sit up straight and maintain excellent posture throughout the day to help ease this problem. 

Regular upper back strengthening exercises can also aid with posture and pain relief by building stronger upper back muscles.

2. Muscle strain

Have you recently done something that needed you to use your upper back muscles? Well, another typical reason for upper back discomfort is muscle strain. 

When your upper back muscles are overworked or overused, this might happen. Lifting heavy things, making abrupt movements, or engaging in vigorous activity without a good warm-up can strain your muscles, resulting in pain and discomfort [2]. 

It’s crucial to use good lifting techniques, to warm up before exercising and to take breaks from repetitive motions so your muscles can recover.

muscle strain
Photograph: Prostock-studio/Envato

3. Injury

Has your upper back lately been damaged, maybe due to a fall or accident? Severe pain may be experienced as a result of upper back injuries, including fractures or sprains. 

Acute or persistent discomfort can result from injuries to the upper back caused by falls, automobile accidents or sports-related mishaps.

You must consult a doctor right away if you think you may have an upper back injury. For a quick recovery, prompt diagnosis and adequate care are crucial.

4. Disc herniation

Do you suffer a sharp ache that travels down your arm from your upper back? The soft cushions that separate the vertebrae in your spine, known as herniated discs or slipped discs, burst or bulge. 

Because of the compression of surrounding nerves, this disease may cause upper back discomfort that may extend down the arm. You could also feel tingling or numbness in the afflicted area in addition to pain [3].

Depending on the severity of the illness, herniated disc treatment options range from conservative methods like physical therapy and pain management to more intrusive interventions like surgery.

5. Osteoarthritis

Do you frequently have discomfort and stiffness in the joints of your upper back, especially after periods of inactivity?

Upper back discomfort may result from osteoarthritis, a degenerative joint condition frequently affecting the spine. 

This illness develops over time when the protecting cartilage in the joints deteriorates, causing swelling, stiffness and discomfort [4]. 

To treat the signs of osteoarthritis and lessen upper back discomfort, doctors frequently advise gentle exercises, physical therapy and anti-inflammatory drugs.

6. Poor ergonomics

Is your workspace ergonomically unsound? Long periods of sitting at a workstation with poor ergonomics can strain your upper back and cause pain. 

Your muscles and joints may be overworked if your workplace is unsuitable for proper posture and comfort.

Upper back discomfort can be caused by various things, including an uncomfortable chair, a desk that is too high or low and a monitor that is not at eye level [5]. 

To enhance ergonomics, put your monitor at eye level to lessen the strain on your neck and upper back, change the height of your desk and chair to encourage good posture, and ensure your chair provides adequate lumbar support.

7. Stress and tension

Do you typically feel a lot of stress or emotional tension? It may surprise you that stress and mental strain may physically show as upper back discomfort.

Our muscles tend to contract when we are under stress and this tension can build up in the upper back, causing discomfort and suffering. 

Stress can also cause bad posture and harmful coping techniques like slouching or tensing the muscles in the upper back.

Developing good coping mechanisms for stress is critical, like using relaxation techniques, exercising frequently and getting help from family, friends or specialists.

Can upper back pain be a sign of a heart attack?

Not every upper back discomfort indicates a heart condition, even if it might occasionally be a sign of a heart attack.

Everyone’s symptoms are unique, so the connection between upper back discomfort and heart attacks can be complicated.

The main sign of a heart attack is chest pain or discomfort, which is frequently characterized as a squeezing or tightness in the chest. The upper back, shoulders, arms, neck and jaw are some examples of additional body parts where the discomfort may occasionally spread. Referred pain is the term for this.

It is important to take into account the concomitant symptoms and risk factors when discussing upper back pain and heart attacks [6]. You should visit a doctor right away if you have severe or chronic upper back pain, especially if it coexists with other symptoms including chest discomfort, difficulty breathing, nausea, sweating, dizziness or pain that radiates down your arm.

Additionally, not all heart attacks exhibit typical symptoms. Instead of conventional chest discomfort, women, elderly people and those with diabetes may encounter unusual symptoms, such as upper back pain.

In order to receive an accurate examination and diagnosis, pay attention to any unusual or chronic discomfort in the upper back. Avoid making snap judgments or self-diagnosing a heart attack based just on upper back discomfort. 

To identify the source of the pain and ensure the right course of therapy, a prompt medical examination is essential. A medical expert will be able to evaluate your symptoms, carry out the required tests and offer an accurate diagnosis to ascertain the underlying reason for your discomfort.

Remember, early intervention is key in managing heart conditions and seeking medical attention promptly can potentially save lives.

How do I get rid of upper back pain?

Even while it’s not always feasible to completely prevent upper back discomfort, there are steps you may do to lessen the risk and the frequency and intensity of episodes. 

You may support a robust and resilient upper back and possibly avoid or lessen upper back discomfort by adding healthy practices into your daily routine. 

Here are some precautions to take into account:

1. Keep a healthy posture

Upper back discomfort is frequently caused by poor posture. Throughout the day, whether you are sitting, standing, or walking, pay attention to your posture. 

Avoid slouching or hunching over and maintain a straight spine and back. To encourage good posture, think about ergonomic solutions like an ergonomic chair or a standing desk.

2. Engage in regular exercise

Regular exercise will help your upper back muscles get stronger, improving your capacity to support your spine and maintain excellent posture. 

Include exercises that work the upper back, such as planks, rows and shoulder presses. Additionally, activities like swimming, yoga and Pilates that increase flexibility and general fitness might be beneficial for your upper back health.

Prevent overuse or overtraining your muscles
Photograph: drazenphoto/Envato

3. Prevent overuse or overtraining your muscles

Overusing or overstraining your upper back muscles can cause pain and discomfort. Use good body mechanics, take pauses and pay attention to your body’s limits when performing tasks that require lifting, carrying, or repeated actions. 

When required, use assistive equipment or seek assistance to lessen the tension on your upper back.

4. Control your stress levels

Tension and stress can cause physical symptoms, including a sore upper back. Find healthy coping mechanisms for stress, such as deep breathing exercises, meditation, regular exercise, indulging in hobbies or getting help from family, friends or specialists. 

You may ease the muscular tension that causes upper back discomfort by lowering your stress levels.

5. Practice proper lifting techniques

When lifting something heavy, maintain your back straight, bend your knees and lift the weight with your leg muscles. As much as you can, avoid twisting or jerking actions, which might strain your upper back.

Practice good lifting methods since bad lifting skills can cause upper back injuries and muscular tension. 

6. Ensure proper ergonomics

Make sure your workspace and everyday activities are ergonomically friendly by evaluating them. To encourage good posture, sit in an ergonomic chair and set your desk at the optimum height. 

In addition, to prevent pressure on your neck and upper back, raise the computer screen to eye level. For other tasks like driving or using portable gadgets, make ergonomic adaptations.

[1] www.medicalnewstoday.com/articles/323839
[2] my.clevelandclinic.org/health/symptoms/22866-upper-back-pain
[3] www.massavechiro.com/blog/how-other-body-parts-can-be-affected-by-a-herniated-disc
[4] www.cdc.gov/arthritis/basics/osteoarthritis.htm
[5] uhs.umich.edu/computerergonomics
[6] nortonhealthcare.com/news/back-pain-heart-attack/

Photograph: gstockstudio/Envato

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Electrically stimulating the vagus nerve — the main set of nerve fibers that control involuntary bodily functions — significantly reduced blood loss and sped up clot formation after injury in a mouse model of hemophilia A, according to a recent study.

Controlling bleeding by stimulating the vagus nerve was just as effective as factor VIII (FVIII) replacement therapy, the current gold standard treatment for treating hemophilia.

“From the delivery room to the operating room and the military battlefield, bleeding is too often fatal and we do not have one universal therapy or technology to help reduce it, or even better, prevent it from occurring,” Jared Huston, MD,  an assistant professor in the Institute of Bioelectronic Medicine at the Feinstein Institutes of Medicine, and the study’s senior author, said in a press release. “This research is an important step toward discovering improvements in patient care, not only for those living with hemophilia, but also for any patient or individual facing a high-bleeding risk scenario.”

Huston is also an associate professor of surgery and science education at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell.

The study, “Vagus nerve stimulation primes platelets and reduces bleeding in hemophilia A male mice,” was published in Nature Communications.

Patients with hemophilia have excessive, uncontrolled bleeding that stems from a lack of certain proteins needed for clotting. In hemophilia A, where the FVIII protein is absent, patients are usually treated with replacement therapy to supply the body with a lab-made version of FVIII.

Some patients will develop inhibitors, a type of neutralizing antibody against the proteins, that can render treatment less effective.

The vagus nerve, which runs through the neck, acts as a means of communication between the brain and the body. By interacting with all the major organs, it controls essential involuntary bodily functions, such as heart rate, breathing, and immune function. Not much was known about its role in blood clotting before this study, however.

“The vagus nerve is the main communication line between the brain and the body’s organs, but no one before suspected it can control blood clotting,”  said Kevin J. Tracey, MD, president and CEO of the Feinstein Institutes.

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An illustration of a lab scientist.

Stimulating the vagus nerve to control bleeding

The researchers found that five minutes of vagus nerve stimulation before a tail injury led to up to 75% less blood loss, which was comparable to the 64% reduction seen with preventive FVIII replacement therapy. The time it took for a clot to form in the hemophilia A mice was also significantly shorter after stimulating the vagus nerve, reaching rates similar to healthy mice.

Vagus nerve stimulation wasn’t able to control bleeding in mice whose spleens had been removed, however. The spleen stores about a third of the body’s platelets, the cell fragments involved in blood clotting.

Controlling bleeding by stimulating the vagus nerve was found to be dependent on a population of immune T-cells in the spleen that increase the levels of acetylcholine, a nerve signaling chemical. The process requires acetylcholine to bind to a family of proteins called alpha-7 nicotinic acetylcholine receptors (alpha-7 nAChRs) on the surface of platelets. In turn, the receptors increased calcium levels inside platelets, priming their activation and promoting blood clotting in an area where there’s been an injury.

The researchers said it’s still not clear “how long circulating platelets remain in a primed state after vagus nerve stimulation or if repeated stimulation is required to maintain enhanced platelet function.”

Stimulating the vagus nerve appeared to only promote local clot formation around an injury and didn’t induce systemic blood clotting that could affect blood flow throughout the body or cause tissue damage.

Vagus nerve stimulation has been in use for depression and epilepsy for decades. Implantable pulse generator devices have been deemed safe and well tolerated by regulatory agencies. Other noninvasive approaches are also under development. Researchers believe such devices could be effective alternatives to medications that may be costly or have unwanted side effects.

“Because hemophilia A affects hundreds of thousands of individuals and causes significant morbidity and mortality, it will be interesting to further study the role of vagus nerve signaling for this and other bleeding disorders,” the researchers wrote.

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Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death in the world and is associated with increasing economic costs and social burdens.1,2 Although spirometry is the gold standard for the clinical measurement of COPD, it does not provide sufficient essential information on exacerbation, leading to worsening respiratory impairment and prognosis.3

Exacerbation of COPD decreases the quality-of-life, causes respiratory dysfunction, and adversely affects prognosis. Numerous studies have discussed exacerbation and risk factors. The prognostic factors of COPD vary between smoking status, degree of dyspnea, severity of airflow limitation, degree of emphysema, exercise tolerability, and physical inactivity.4–6 Recent reports have also described the impact of the neutrophil-lymphocyte ratio (NLR)7 and the existence of asthmatic components.8

The nutritional status of a patient has also been established as a prognostic factor for various chronic diseases.9 Since Japan and Western countries have entered the era of an unprecedented ultra-aging society,10 there has been a focus on nutritional status as a risk factor for chronic diseases, especially in elderly patients.11 For example, malnutrition is common in elderly patients with heart failure, with evidence showing that nutritional status is strongly linked to their prognosis.12

In 1980, Buzby et al suggested the concept of the prognostic nutritional index (PNI).13 Subsequently, Onodera et al proposed that PNI could be calculated easily using serum albumin level and total lymphocyte count and showed that the index was a risk indicator for postoperative complications and prognosis for patients undergoing gastrointestinal cancer surgery.14 Subsequent studies reported a relationship between PNI and clinical outcomes in various other malignant diseases.15–17

Nutritional status has also been reported to be a significant prognostic indicator in patients with COPD.18 Previously, the body mass index (BMI) was the health indicator mainly used to assess prognosis in COPD.19 It remains unclear, however, whether the PNI is related to COPD exacerbations and prognosis of elderly patients.

Therefore, the aim of the present study was to elucidate whether PNI was associated with exacerbation and to clarify the clinical value of assessing the immune-nutritional status in elderly patients with COPD.



This prospective, observational study enrolled 139 subjects who presented to Chiba University Hospital from March 2014 to June 2019 for management of COPD. The subjects were required to meet all of the following inclusion criteria: (a) ≥ 40 years; (b) smoking history ≥ 10 pack-years; (c) COPD diagnosed or suspected to have COPD based on subjective symptoms/other findings/pulmonary function tests/imaging findings; (d) no history of acute exacerbation or hospitalization within 2 months. Exclusion criteria were any of the following: (a) obvious respiratory diseases other than COPD; (b) any malignancy within the past 3 years; (c) severe heart failure; (d) currently receiving oral systemic corticosteroids; (e) deemed unsuitable for inclusion by investigators for any other reason.

At enrollment, eight subjects were excluded for the following reasons: one never-smoked without a history of smoking; three with malignant neoplasms; one prescribed a steroid and an immunosuppressive agent; one with severe heart failure; and one with a tracheostomy. During the follow-up period, one subject was excluded as they decided to withdraw from participating in the study. 40 subjects were excluded by the end of follow-up due to discrepancies in each data set, such as a discontinuation of hospital visits, confirmation of worsening symptoms, COPD assessment test (CAT), pulmonary function tests, and chest CT scans. Finally, 91 subjects with COPD were enrolled in the study (Figure 1).

Figure 1 Flow chart of the study subjects.

The diagnosis of COPD was made comprehensively by respiratory specialists according to the recommendations of the American Thoracic Society (ATS) and European Respiratory Society (ERS),20 that included the subject’s smoking history, respiratory symptoms including dyspnea, cough and sputum, physical examination, spirometry results. Pulmonary function tests (PFTs) were performed using a Fudac-60 (Fukuda Denshi, Tokyo, Japan) and included forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1), which were expressed as their predicted values based on the Japanese Respiratory Society (JRS) guidelines.21 The subjects underwent a CAT, PFTs, laboratory tests, and multidetector computed tomography (MDCT) at the time of enrollment. The CAT is a simple tool for comprehensively evaluating the clinical symptoms of subjects with COPD,22,23 and consists of eight items rated on a scale of 0 to 5, and is an excellent indicator for assessing respiratory and extrapulmonary symptoms.

This study was conducted in accordance with the Declaration of Helsinki. The Ethics Committee of the Chiba University School of Medicine approved the study protocol (approval number, 857). Written, informed consent was obtained from all the study subjects.

Calculation of the Prognostic Nutritional Index

As an immune-nutritional index, the PNI was calculated as follows, in accordance with the original description of Onodera et al14 10 x serum albumin level (g/dL) + 0.005 x total lymphocyte count (×103/μL). Originally, the PNI was used to assess surgical risk for gastrointestinal malignancies, with a resection anastomosis contraindicated in subjects with PNI values ≤ 40.

MDCT Scanning and CT Measurements of Low Attenuation Volume

All CT studies were performed on a 64-MDCT Aquilion ONE and Aquilion PRIME (Canon Medical Systems, Otawara, Tochigi, Japan) at full inspiration, with no contrast medium being used. The CT parameters used were as follows: collimation 120kV; CT-AEC; gantry rotation time, 0.5s; and beam pitch, 0.70–0.83. All the images were reconstructed using standard reconstruction algorithms, with a slice thickness of 0.5 mm and a reconstruction interval of 0.5 mm. The reconstructed CT images were transferred to a commercial workstation (Ziostation2, Ziosoft Ltd., Tokyo, Japan). Total lung volume (LV) and low attenuation volume (LAV) were measured based on a threshold of −950 Hounsfield units (HU). LAV% was calculated as 100%×LAV/LV.24

Clinical Events

We investigated the clinical events during a two-year observation period. The clinical events were identified as COPD exacerbations. An exacerbation was defined as a worsening of COPD requiring a change in therapy, the use of antibiotics or steroids, and/or hospital admission.25

Statistical Analysis

The results were expressed as means ± standard deviation (± SD) or as medians (interquartile range [IQR]) as appropriate. Categorical data were expressed as the number (%). After confirming the normality of the study parameter data, the correlations between PNI and CAT, and LAV%, and FEV1%pred were assessed by Spearman rank correlation analysis, as appropriate. For clinical outcome, comparisons between the subject groups with or without an exacerbation requiring treatment changes were performed using the Mann–Whitney U-test for continuous variables and the chi-square test or Fisher exact test for categorical variables.

For the selection of variables in the multivariate analysis, we used those that showed a causal relationship with COPD exacerbations based on previous reports7,25–27 and those that were significant in our univariate analysis. The association of selected variables with clinical outcome was assessed by univariate logistic regression analysis, and significant variables in this analysis then entered into a multivariate logistic regression analysis.

The variables selected were age, CAT as a comprehensive indicator of subjective symptoms, NLR as an indicator of the level of inflammation, PNI as an indicator of nutrition and immunity, FEV1% pred as an indicator of airflow limitation to measure disease severity, and LAV% as an imaging indicator to determine the degree of emphysema. In accordance with previous reports, CAT was treated as a continuous variable in the analysis.28,29

In the group with subjects aged > 75 years, we also calculated the areas under the receiver operating curve (ROC) analysis for using PNI and CAT to predict COPD exacerbation, with the optimal cut-off of the PNI and CAT determined by the Youden index. In addition, based on Akaike’s information criterion,30 we examined whether PNI improved the predictive accuracy of the analytical model for exacerbations in the elderly group. The original model was constructed with items that were significant in the univariate analysis. A statistically significant increase in the global chi-square of the model was interpreted as indicating an increase in prognostic value.31,32 All the statistical analyses were performed by JMP Pro version 14.0 software (SAS Institute, Cary, NC, USA). For all the statistical analyses, the level of significance was set at p <0.05.


Subject Characteristics

The clinical characteristics of all the subjects are presented in Table 1.

Table 1 Characteristics of the Total Subjects (Comparison of the Group Aged<75 Years vs the Group Aged ≧75 Years)

In the total subjects (n=91), 34 subjects were aged ≥75 years (33 males and 1 female; mean age, 78.3 ± 3.2 years) and 57 subjects were aged < 75 years (54 males and 3 females; mean age, 67.2 ± 6.2 years). There were no differences between the two groups for sex, body weight, height, BMI, and CAT score. For the pulmonary function tests, VC and FVC were lower in subjects ≥75 years than in those aged <75 years. LAV% in the group aged ≥75 years was also lower than that measured in subjects <75 years. For nutritional status, there was no significant difference in PNI between the two groups, although albumin was slightly lower in the group aged ≥75 years. An exacerbation occurred in 21 of 57 of the younger subjects (36.8%) compared to 10 of the 34 older subjects (29.4%). The median duration of follow-up was 735 days.

Comparisons of the clinical indices in subjects aged ≥75 years with or without an exacerbation are shown in Table 2. In the exacerbation group, the CAT score was significantly higher and PNI was significantly lower compared to those measured in the non-exacerbation group. The serum albumin levels were also significantly different between the two groups.

Table 2 Characteristics of COPD Subjects in the Group Aged ≧75 Years (Comparison of the Exacerbation and Non-Exacerbation Groups)

Comparisons of the clinical indices in subjects aged <75 years with or without an exacerbation are shown in Table 3. In the exacerbation group, the CAT score, LAV%, WBC count, and neutrophil count were significantly higher than those measured in the non-exacerbation group. The BMI was significantly lower in the exacerbation group than in the non-exacerbation group. Obstructive impairment was also significantly more severe in the exacerbation group compared to that observed in the non-exacerbation group.

Table 3 Characteristics of COPD Subjects in the Group Aged <75 Years (Comparison of the Exacerbation and Non-Exacerbation Groups)

Associations Between the Prognostic Nutritional Index and Airflow Limitation and Pulmonary Emphysema

The associations between the PNI and other clinical indices in the entire cohort of subjects are shown in Figure 2. The PNI showed no significant association with CAT (r= −0.20, p=0.06). Similarly, there was no significant correlation between PNI and either FEV1%pred (r= 0.03, p=0.78) or LAV% (r=0.03, p= 0.75).

Figure 2 The relationship between PNI and CAT and FEV1%pred and LAV% in all the subjects.

Abbreviations: PNI, prognostic nutritional index; CAT, COPD assessment test; FEV1, forced expiratory volume in one second; LAV%, low attenuation volume percentage.

Notes: The associations between the PNI and other clinical indices are shown for the entire cohort of subjects (n=91).

Clinical Factors Associated with Exacerbation Events

The results of the univariate and multivariate analyses for exacerbation in the two groups grouped according to age are shown in Table 4 and Table 5.

Table 4 Results of the Logistic Analysis of COPD Exacerbation in the ≧75 Year Age Group

Table 5 Results of the Logistic Analysis of COPD Exacerbation in the<75 Year Age Group

In the group aged ≥75 years, univariate analysis showed that CAT (OR = 1.15, 95% CI = 1.03–1.29, p = 0.013), NLR (OR=1.70, 95% CI=1.01–2.86, p =0.046), and PNI (OR = 0.74, 95% CI =0.58–0.96, p = 0.023) were associated significantly with exacerbation. Multivariate analysis identified CAT as an independent factor for exacerbation (OR = 1.15, 95% CI = 1.00–1.33, p = 0.047), while PNI showed a trend of being associated with exacerbation (OR = 0.73, 95% CI =0.52–1.02, p = 0.063).

ROC curve analysis was performed for the group ≥75 years of age to evaluate the accuracy of CAT and PNI and to identify the value of the cut-off points. ROC curve analysis in the group ≥75 years of age demonstrated that the optimal cut-off values for CAT and PNI to predict events were 14.0 (sensitivity, 0.80; 1-specificity, 0.21; area under the curve [AUC], 0.79; Figure 3a) and 48.85 (sensitivity, 0.90; 1-specificity, 0.33; AUC, 0.82; Figure 3b), respectively.

Figure 3 Receiver operating characteristic curve (ROC) analysis of CAT and PNI in the group ≥75 years of age.

Abbreviations: PNI, prognostic nutritional index; CAT, COPD assessment test.

Notes: ROC curve analysis was used to evaluate the sensitivity and specificity of CAT (a) and PNI (b) for COPD exacerbation in the group ≥75 years of age. (n=34).

In the group aged <75 years, univariate analysis showed that CAT (OR = 1.083, 95% CI = 1.00–1.17, p= 0.038), FEV1% pred (OR = 0.957, 95% CI = 0.931–0.986, p = 0.003) and LAV% (OR = 1.077, 95% CI = 1.032–1.123, p = 0.0007) were associated significantly with exacerbation. Multivariate analysis identified LAV% as an independent factor for exacerbation (OR = 1.074, 95% CI = 1.003–1.149, p = 0.031).

Incremental Value of the PNI in Elderly Subjects with COPD

The incremental value of the PNI in the group ≥75 years of age is shown in Figure 4. CAT was selected as the conventional variable for the prognostic model from Table 4 (Model 1). The addition of PNI to the conventional variable significantly improved the prognostic utility of the model (Model 2, p = 0.0084).

Figure 4 The incremental benefit of adding PNI to the CAT, to predict exacerbation events in the group ≥75 years of age.

Abbreviations: CAT, COPD assessment test; PNI, prognostic nutritional index.

Notes: Model 1, based on CAT, was improved significantly by the addition of the PNI (model 2) in the group ≥75 years of age (n=34).


The key findings of this study were as follows. There were differences in factors related to COPD exacerbations between subjects aged ≥75 years and those aged < 75 years. High CAT values were associated with exacerbation in elderly subjects with COPD, while a combined model of CAT and PNI more accurately predicted COPD exacerbations. In other words, a low PNI in combination with a high CAT increased the risk of an exacerbation in elderly subjects with COPD.

The PNI was calculated using serum albumin levels and the total circulating lymphocyte count. The PNI score has been validated and reported to correlate significantly with subjective global assessment (SGA), a well-established nutritional index and also other nutritional screening tools.33–35 While the SGA is a simple, inexpensive, and quick assessment, it is a subjective assessment that requires skill and experience. In contrast, the PNI is based on the results of peripheral blood tests, thereby allowing a physician to easily and objectively assess the immune-nutritional status of their patients.

Many earlier studies have described that nutrition and immune status are associated closely with tumor progression and prognosis. The PNI reflects both the nutritional and immunological status of patients with a variety of malignancies.36,37 In the respiratory field, the PNI of pretreatment in patients with non-small cell lung cancer has been shown to have prognostic value.38 Recently, it was reported that a lower PNI at the time of admission was related to the risk of mortality in subjects with severe COVID-19.39,40 Regarding chronic respiratory diseases, the present study has shown that the PNI score raised the risk of exacerbation in elderly with COPD.

The CAT is a simple tool for comprehensive evaluation of the clinical symptoms in COPD patients.22 The CAT consists of eight items and is an excellent indicator for assessing respiratory symptoms, such as cough, phlegm, and dyspnea associated with exercise, and extra-pulmonary symptoms, such as activity, insomnia, and energy level. The CAT scores were increased by greater than five points during exacerbations.26 In the present study, the PNI was not associated with CAT in all the subjects. Yoshikawa et al reported that nutritional status using the Mini-nutritional Assessment Short-form predicted COPD exacerbations independently of CAT.41 The present study also showed no significant relationship between PNI and either FEV1%pred and low attenuation volume percentage (LAV%). These findings might indicate that PNI may be an independent predictor from CAT, the degree of obstructive impairment, and emphysema, which have conventionally been reported as predictive factors.42

A cut-off value of 40 for the PNI has been proposed for perioperative evaluation of gastrointestinal cancers.14 In the current study, the cut-off value for PNI for the presence of exacerbations in subjects aged ≥ 75 years was set at 48.85, a value higher than that used for other diseases. A prognostic pretreatment cut-off of 45.5 was used for lung cancer patients receiving immune checkpoint inhibitors.43 Recently, a lower cut-off value of 33 was used for survival in patients with severe COVID-related pneumonia.39 Since COPD is a gradually progressive disease, the serum albumin levels and lymphocyte counts were obtained at the time of consultation, and we speculate that this may be one of the reasons for the higher cut-off values compared to those used for other diseases. Therefore, patients with COPD should be cautioned against exacerbations even if the initial PNI value is higher than previously reported for other diseases.

In the group aged < 75 years, the conventional variables, such as emphysema and the degree of airflow limitation, contributed to exacerbations.25 Most previous studies have focused on relatively young to middle-aged patients, with only a minority carried out in older subjects.44

In the present study we identified prognostic factors for elderly subjects and showed that the complex of subjective symptom scores and immune-nutritional status contributed more to exacerbations than the severity of COPD. The prognosis of elderly patients with chronic diseases is not necessarily determined by the severity of the underlying disease.45 Poor nutritional status is associated with a poor prognosis and exercise intolerance in elderly patients with COPD.41,46 More severe subjective symptoms are associated with a worse prognosis.22 We propose that the combination of CAT and PNI would allow assessment of the risk of exacerbation more accurately in elderly patients with COPD.

Serum albumin level is a conventional marker of nutrition and has been reported to be associated with a poor outcome in many different diseases. On the other hand, the NLR is a reliable indicator of systematic inflammation and has also been investigated as a diagnostic and prognostic marker in COPD.47 Chronic inflammation causes recruitment of the main white blood cell populations, neutrophils and lymphocytes. These factors participate actively in the pathophysiological mechanisms of COPD. A higher NLR has been reported widely to be associated with poor survival in patients with various diseases.48,49 However, the NLR only reflects the inflammation status. In recent studies, the PNI was shown to be superior to the NLR as a prognostic marker in many cancer patients.36,50 PNI as a nutrition plus immunity indicator may therefore be more useful in the evaluation of COPD than either nutrition or immunity alone.

There has been a focus on the role of the asthma-COPD overlap (ACO), including eosinophilia in COPD, and the impact of asthmatic components on the clinical course of COPD.51 Recent studies have reported that eosinophilia in COPD does not affect the clinical course, however, this view is controversial.52 The present study also showed no relationship between eosinophilia and clinical outcome. In recent years, the clinical significance of personalized treatment in COPD has been proposed, with some studies showing that appropriate treatment, such as triple therapy in patients with asthmatic components, decreases symptoms and the risk of exacerbations, thereby contributing to an improved clinical course.53


Our study had some limitations. First, the study only enrolled a relatively small number of subjects and was a preliminary and exploratory investigation conducted at a single institute. Second, the observational period was relatively short. Third, because of the small number of subjects we could not fully evaluate the differences in gender, each treatment, or the rate of smoking cessation. Fourth, we could not perform nutritional intervention. Nutritional intervention may be important for preventing COPD exacerbations, especially in elderly patients.54 And finally, previous papers reporting an association between PNI and prognosis used unadjusted multivariate analyses.43,45 The present study also performed unadjusted multivariate analysis of each item. However, this was a single-center, small-group, exploratory study and therefore a larger cohort is needed to confirm the results of the current study that would also require more rigorous examination and exclusion of confounding factors. Further prospective studies on larger study populations and a longer observational period are therefore required to confirm our results.


In elderly subjects with COPD, CAT was associated significantly with the risk of COPD exacerbation, with PNI also a potential predictor. The combined assessment of CAT and PNI may be a useful prognostic tool in patients with COPD.


BMI, body mass index; CAT, chronic obstructive pulmonary disease assessment test; COPD, chronic obstructive pulmonary disease; FEV1, forced expiratory volume in 1 second; FEV1/FVC, forced expiratory volume in 1 second per forced vital capacity; FVC, forced vital capacity; GOLD, Global Initiative for Chronic Pulmonary Obstructive Lung Disease; ICS, inhaled corticosteroid; LAA, low attenuation area; LABA, long-acting β-2 agonist; LAMA, long-acting muscarinic antagonists; LAV, low attenuation volume; LAV%, low attenuation volume percentage; LV, lung volume; MDCT, multi-detector row computed tomography; MRI, magnetic resonance imaging; NLR, neutrophil-to-lymphocyte ratio; PFT, pulmonary function testing; PNI, prognostic nutritional index; TLA, total lung area; VC, vital capacity; %VC, vital capacity percentage; WBC, white blood cell.

Data Sharing Statement

The data sets analyzed during the current study are available from the corresponding author upon reasonable request.


The abstract of this paper was presented at the 2020 European Respiratory Society (ERS) International congress in session “Respiratory viruses in the”pre-COVID-19 “era”, with interim findings. The poster’s abstract was published in “Poster Abstracts” in European Respiratory Journal 2020; 56: Suppl. 64, 5114. erj.ersjournals.com/content/56/suppl_64/5114.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.


This research was partially supported by the Ministry of Education, Science, Sports and Culture, Grant-in-Aid for Scientific Research (C) (19K12816 and 22K12836), and the Chiba Foundation for Health Promotion & Disease Prevention (No.1272). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.


The author reports no conflicts of interest in this work.


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Guwahati: Covid survivor Nikhilesh Dutta, who fought the virus during the deadly second wave of the pandemic and was hospitalised for nasal bone surgery a few months later in 2021 that compelled him to skip last year’s Class 12 state board exam, pulled off a spectacular success by becoming the state topper in science this year as a private candidate.
Nikhilesh, who hails from Ramdia in Hajo area in lower Assam’s Kamrup district lost his uncle (elder brother of his father), who was a mentor and guide for the joint family, to Covid. Seven members of the family were infected by coronavirus.
In October 2021, just a few months before he was scheduled to appear in Class 12 board examination, he had to undergo the nasal bone surgery in Chennai and it took almost four months for him to recover fully.
By then the exams were just weeks away and the teachers advised him not to appear in the exam due to lack of preparation.
A brilliant student since childhood, Nikhilesh got eighth rank in Class X boards and losing an academic year hurt him. But Nikhilesh had full faith in his capabilities. “Covid almost shattered our dreams. After I recovered from Covid by June, I had breathing problems. I had to undergo surgery in Chennai in October 2021 and could not prepare for board exams. Losing an academic year was painful as I could not appear in the board exam next year,” Nikhilesh told TOI. Nikhilesh’s family took advice from the teachers who suggested skipping the board exam for a year so that below-par performance does not upset him.
Nikhilesh’s father Nagendra Nath Dutta, a retired teacher of Ramdia Girls HS School, was overjoyed at his son’s success. “We had full faith in Nikhilesh’s calibre. Had he not fallen ill, Nikhilesh could have tasted success last year itself,” said Nagendra Nath. He expressed gratitude to Ramanujan Senior Secondary School, where Nikhilesh studied in Class 11 and 12, for giving him the opportunity to do regular classes for an extra year.
Nikhilesh appeared in the all-India medical entrance NEET this year and is eagerly waiting for the results. “There are many entrance tests ahead but I would love to study medical science to serve the society,” he said.

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A Perth toddler has died suddenly from the flu after being admitted to hospital late last month.

Muhammed Saadiq Segaff, 3, went into respiratory distress prompting open heart surgery but could not be saved, it's been reported.

The three-year-old's symptoms began with wheezing but he rapidly deteriorated and was rushed to Fiona Stanley Hospital in Murdoch, Western Australia. He was later transferred to the Perth Children’s Hospital where he was put on life support, but his parents decided to turn it off on May 26.

Tests revealed the toddler has influenza A making him WA's youngest flu death this year, The West Australian reported overnight. Muhammed's parents said their son was a "cheeky, happy and always smiling" little boy who they said was otherwise perfectly healthy.

Muhammed Saadiq Segaff Perth toddler

Muhammed Saadiq Segaff, 3, died from the flu last week. source: GoFundMe

Healthy children still at risk of serious flu

On average, between five and 10 Australian children are reported to die from influenza each year, according to The Royal Australian College of General Practitioners (RACGP). Many deaths occur in previously healthy children with those under five more likely to be hospitalised.

Perth Children’s Hospital Infectious Diseases Specialist Dr Chris Blyth said about 10 per cent of children admitted with the flu are sent to the hospital's intensive care unit. "We have a significant and effective prevention strategy for flu, it’s a flu vaccine,” Dr Blyth warned.

Perth Childen&#39;s hospital.

On average, between five and 10 Australian children are reported to die from influenza each year. Source: Getty

Signs of influenza in children

Common symptoms to look out for include fever, cough, headache, a sore throat and a runny nose. The virus can also infect the lungs, causing pneumonia, the RACGP website reads.

Dr Blyth said "fast breathing and breathlessness is a worrying sign in children" as it can affect the brain. "So confusion or drowsiness is another important sign. Both of those things would make me want to seek medical advice," he told 7News.

There have already been over 40,000 cases of laboratory-proven influenza so far in 2023, with more than 8,173 cases diagnosed in the first half of May alone, according to the Australian Government’s National Notifiable Diseases Surveillance System.

Since his death, over $27,000 has been raised for Muhammad's family in an online fundraiser.

Do you have a story tip? Email: [email protected].

You can also follow us on Facebook, Instagram, TikTok and Twitter and download the Yahoo News app from the App Store or Google Play.

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What is Cortisol?

Cortisol is a hormone that is made and released by the adrenal glands. Hormones are chemicals that help synchronise the various functions in your body. They carry messages from your blood to the different organs and help your body fulfill its various functions. Adrenal glands are small, triangular glands located on top of your kidneys. 

Cortisol is your body’s main stress hormone. It is called the stress hormone, as its levels in your body increase when you are faced with a stressful situation. 

Let us understand more about stress and the role of cortisol in the body and how high levels of cortisol can affect your health.

Stress and the Role of Cortisol in Your Body

Cortisol is an important hormone that prepares your body to face stressors of different types. When you sense danger, your body prepares you for fight or flight to protect yourself. 

For example, when you encounter a stressful situation, such as an accident on the road, your hypothalamus, which is a tiny area at the base of your brain, sets an alarm in your body. With the help of hormonal signals, the alarm system prompts your adrenal glands to release cortisol and adrenaline.

While adrenaline increases your heart rate and your blood pressure, cortisol, which is the main stress hormone, increases sugar (glucose) in your blood and also your brain’s use of glucose.

It increases muscle tension and halts the digestive system, which causes nausea, vomiting and diarrhoea

Such an effect of cortisol causes discomfort and fear, but it helps you to protect yourself and your loved ones from danger and carry out survival strategies. 

Once the stress has passed, cortisol and adrenaline levels decrease, your heart rate and blood pressure return to normal and the other systems also resume their normal activities. 

What Does Cortisol Do to Your Body? 

Cortisol is a vital hormone that plays many essential roles, as follows:

  • It maintains your body’s response to stress.
  • It controls how your body uses fats, proteins and carbohydrates.
  • It regulates blood pressure.
  • It maintains blood sugar.
  • It controls inflammation.
  • And, it controls your sleep-wake cycle.

What are the Other Effects of Cortisol on your Body?

Every cell in your body has cortisol receptors; therefore, cortisol affects every organ and system in your body in the following ways:

  • It helps in the formation of memory.
  • It acts as an anti-inflammatory.
  • It regulates the functioning of your immune system.
  • It regulates your growth.
  • And, it maintains the balance of salt and water in your body.

Symptoms of High Levels of Cortisol in the Body

Having high levels of cortisol for a long time is considered Cushing’s syndrome. Symptoms of Cushing’s syndrome are as follows:

  • Type 2 diabetes
  • High blood pressure
  • Osteoporosis or weak bones
  • Muscle weakness in upper arms and thighs
  • Fatty deposits between the shoulder blades
  • Weight gain
  • Mood swings, anxiety and depression
  • Purple stretch marks on the stomach
  • Increased thirst and frequent urination
  • Excessive hair growth

What Causes High Levels of Cortisol?

Your body monitors your cortisol levels continuously, as higher than normal or lower than normal cortisol levels can harm your body. However, certain factors cause high levels of cortisol in your body, which include the following:

  • Stress: Stress and cortisol go hand in hand. Constant stress can cause high levels of cortisol as you feel you are constantly under attack
  • Medications: Certain medications, such as corticosteroids that are used to treat asthma, arthritis and some cancers, if taken in high doses for long periods cause high levels of cortisol.
  • Adrenal Gland Tumours: Adrenal gland tumours can be cancerous or noncancerous and can produce high levels of cortisol.
  • Neuroendocrine Tumours: Neuroendocrine tumours in other organs, such as the lungs, can also cause high cortisol levels in your body.
  • Pituitary Gland Issues: The pituitary gland is located at the base of your brain. Conditions related to the pituitary gland, such as tumours, can trigger the adrenal glands to release excess cortisol.

What are the Treatment Options to Reduce Cortisol Levels?

If you experience symptoms of Cushing’s syndrome, your doctor may suggest the following:

  • Cortisol urine (Cortisol – Free Urine 24H) and blood tests to measure the level of cortisol in your blood and urine
  • Cortisol saliva test to check if you have high cortisol levels
  • CT scans or MRIs to observe your pituitary and adrenal glands for tumours or any abnormalities.

If you have very high levels of cortisol or Cushing’s syndrome, you will need medications or surgery.

To lower your stress and cortisol levels, you can try the following practices:

  • Learn to manage stress by being aware of your thoughts, breathing, heart rate and other signs of tension. This will help you recognise stressful thinking and curb it before it worsens.
  • Make regular exercise a part of your everyday schedule. Exercise lowers cortisol levels, reduces stress and releases feel-good hormones called endorphins. Exercising also helps improve your mood and sleep. 
  • Get enough sleep. Chronic sleep issues like insomnia and sleep apnea increase cortisol levels. Create a sleep schedule and turn off digital gadgets an hour before bedtime for better, uninterrupted sleep.
  • Practice deep breathing exercises to relieve stress and lower cortisol levels. 
  • Practice meditation. It helps you manage your stress, increase awareness and focus on the present moment. Meditation also helps you look at stressful situations from a new perspective. 

Summing Up

Please consult your doctor or a therapist if you find it difficult to manage everyday stress. Chronic stress and cortisol are linked to anxiety, depression, high blood pressure, heart disease and diabetes. Making lifestyle changes and learning to manage stress will help you live a healthy and happy life. 

To measure your cortisol levels, your doctor may order cortisol urine and blood tests. Always get these tests done at a certified pathological laboratory like Metropolis Healthcare. Metropolis is India’s leading diagnostic service provider that guarantees quick results to ensure timely treatment. 



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Roughly a week after the Super Bowl, a half-mile walk presented a significant challenge for Lane Johnson.

The right tackle started his offseason with surgery to repair a torn adductor in his groin, suffered just before the start of the Eagles’ playoff run. Less than seven days after the Eagles’ Super Bowl LVII loss to the Kansas City Chiefs, Johnson was in the early days of postoperative rehabilitation, which challenged him to progress more quickly than some of the rehabs he has experienced in the past.

He said he needed to walk about a half mile in his first day after surgery, which was no small feat. Healing without the activity, though, would have led to lingering discomfort.

“The last thing they want you to do is get surgery and not move and kind of heal up stiff,” Johnson said during a news conference Tuesday. “That’s the worst fear, healing up stiff. When you do that, there might be a lot of scar tissue broken up later, so I think the more progressive you are early in the rehab, the less stuff you have to deal with in the latter half of it.”

» READ MORE: Olamide Zaccheaus’ path to the Eagles began with his mother, a Nigerian immigrant,

Johnson, 33, said he completed his rehab process in time for the start of the Eagles’ organized team activities, which began last week, and has been fully cleared for “a little while.” The early days were the most difficult, but eventually they gave way to a process he described as easier than the road back from ankle surgery in 2021.

“I felt like this was a lot easier than the ankle that I had a few years ago,” Johnson said. “I’m feeling good, moving good.”

The tackle spoke to reporters for the first time since signing a contract extension that tacked on one year to his existing deal for another $33.445 million in 2026.

The move helped the Eagles spread his salary-cap hit next season into future years, offering some short-term flexibility in exchange for a raise for Johnson, who has been one of the best offensive linemen in the NFL the last few seasons.

“It wasn’t too long of a process,” Johnson said. “A few weeks. Obviously we had to get some stuff worked out to get it done, but it’s a good situation for both, lowering the cap room and I got a little bit more money. At the end of the day, that’s why I think we’re so good — we know how to work the numbers and get players and maneuver the cap room.”

Johnson said he expects his current deal to carry him to his retirement. His play would not suggest an end to his career any time soon. He hasn’t allowed a single pressure in the last two seasons, the longest streak in the NFL over that time, according to Pro Football Focus.

Johnson, the fourth pick in the 2013 NFL draft, made his second All-Pro team last season and is still playing at a high level, but has conceded before that he plans to play only a few more seasons. No matter the exact number, Johnson said the end of this deal should cover him barring the unlikely scenario where he follows in the footsteps of former Eagles tackle Jason Peters, who played for the Cowboys last season at 41 years old.

» READ MORE: D’Andre Swift is eager to join the Eagles offense and wants to be ‘a piece of the puzzle’

“Thirty-seven would be pretty old,” Johnson said. “Then again, JP is 41.”

“I’m super fortunate to be where I’m at,” Johnson added. “Being in the second half of my career, my goal now is to develop the younger guys and bring those guys along in the O-line room and be a better leader, but it’s crazy how fast time flies.”

When asked if he’s more focused on avoiding regression or finding ways to improve at this point in his career, Johnson said there are still areas where he’d like to get better. Chief among them is his ability to move people in the running game, something he suggested took a hit because of his long recovery from ankle injuries that sidelined him for parts of the 2019 and 2020 seasons.

“I think it improved last year,” Johnson said about his run blocking. “But I’m really trying to get back on track where I’m feeling comfortable like I was earlier in my career and not having to favor one leg or the other. I feel like I have to complete that part of my game and keep adding.”

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“These investments highlight what the new markets tax credit investment sets out to do in communities all across the country,” said Greg Clements, Novogradac partner and conference chair. “They represent a wide swath of investments that help in rural and urban low-income communities.”

Thirteen community development entities (CDEs) that made qualified low-income community investments (QLICIs) in five businesses have been named winners of the Novogradac Journal of Tax Credits QLICIs of the Year awards for 2023.

The awards go to new markets tax credit (NMTC) stakeholders who strive for excellence in community development. This year’s winning CDEs earned the awards for the following investments:

  • DC Central Kitchen’s Klein Center for Jobs and Justice in Washington, D.C., as Metro QLICI of the Year.
  • Lauderdale Community Hospital in Ripley, Tennessee, as Nonmetro QLICI of the Year.
  • The Freelon at Sugar Hill in Detroit as Real Estate QLICI of the Year.
  • Detroit Food Commons in Detroit as Small Business QLICI of the Year.
  • Santa Cruz Community Health Centers–Live Oak Health Clinic in Santa Cruz, California, as Operating Business QLICI of the Year.

The winners will be honored at the Novogradac 2023 Spring New Markets Tax Credit Conference June 8-9 at The Fairmont in Washington, D.C.

“These investments highlight what the new markets tax credit investment sets out to do in communities all across the country,” said Greg Clements, Novogradac partner and conference chair. “They represent a wide swath of investments that help in rural and urban low-income communities.”

DC Central Kitchen’s Klein Center for Jobs and Justice in Washington, D.C., is a new, 36,000-square-foot facility that serves as a 15-hour-a-day alternative to the traditional soup kitchen and includes a culinary training kitchen and production kitchen capable of producing 25,000 meals per day. CDEs CAHEC New Markets, Reinvestment Fund and Chase New Markets Corporation allocated a combined $18.5 million in QLICIs.

Lauderdale Community Hospital replaces an aging hospital in rural Ripley, Tennessee, giving a multimillion-dollar upgrade to improve and expand its services for patients and staff due to NMTCs allocated by three CDEs. Upgrades include emergency cardiac and pulmonary rehabilitation, surgery services, radiology, laboratory, physical rehabilitation, acute care and respiratory care. DV Community Investment, Hope Enterprise Corporation and CCG Community Partners combined on $22 million in QLICIs.

The Freelon at Sugar Hill, a mixed-use development in Midtown Detroit’s Sugar Hill Arts District, will provide high-quality modern housing options, including units set aside for veterans, as well as commercial space for properties that are either woman- or immigrant-led. Building America CDE, Michigan Community Capital, Cinnaire New Markets and PNC Community Partners combined for $29.5 million in QLICIs for the endeavor.

The Detroit Food Commons a 31,000-square-foot, two-story building in Detroit’s North End neighborhood, will house the Detroit People’s Food Co-op–a community-owned, full-service grocery store including a deli and a café–on the first floor. On the second floor, there will be four teaching and shared-use commercial kitchens, a banquet hall/community meeting space and office spaces for the Detroit Black Community Food Security Network. New Markets Support Company, Michigan Community Capital and U.S. Bancorp Impact Finance combined to allocate nearly $20 million in QLICIs.

Santa Cruz Community Health Centers–Live Oak Health Clinic in Santa Cruz, California, will help an additional 3,000 patients and accommodate 20,000 visits annually at the new health clinic. SCCHC is a federally qualified health center and a Health Resources & Services Administration-designed Healthcare for the Homeless provider. Primary Care Development Corporation and HEDC New Markets combined for $14.4 million in QLICIs for the development.

Additional details about the award winners and information on how to nominate a development for the 2024 round of awards can be found at www.novoco.com/events/awards.

About Novogradac

Novogradac began operations in 1989 and has grown to more than 700 employees and partners with offices in more than 25 cities. Tax, audit and consulting specialty practice areas for Novogradac include affordable housing, community development, historic rehabilitation and renewable energy.


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Claire smiling

No one expects to get any sleep with a new baby. It takes a while for babies to settle into a sleep cycle, and they have to eat often. Yet these usual reasons are not what kept Katie and Ryan Bridge awake when their daughter Claire was just 4 weeks old. It was her noisy breathing.

“It got so loud that we couldn’t sleep,” says Katie. “Our friend said she sounded like a goose honking.”

Because Claire wasn’t fussy, the couple didn’t think her noisy breathing was too worrisome, but they contacted their pediatrician to be on the safe side. She responded immediately and set up a same-day appointment with a specialist at a nearby clinic.  

“The specialist said her noisy breathing was called stridor and that it was really bad. She called Stanford Medicine Children’s Health, and Claire had a scope with Douglas Sidell, MD, FACS, an airway specialist, the very next day,” Katie says.

Diagnosing laryngomalacia, a common airway condition

Dr. Sidell performed an in-office laryngoscopy—a simple procedure whereby a small flexible camera is passed through the nose to view the larynx, or voice box. He quickly diagnosed Claire as having laryngomalacia, a condition in which floppy tissue above the vocal cords falls into the airway when a baby breathes in, resulting in stridor. Stridor is a noise that is caused by turbulent airflow as it passes through the voice box or trachea (the windpipe). When there is obstruction, it causes high-pitched noisy breathing, and the obstruction from laryngomalacia can be visualized on the laryngoscopy.

“Dr. Sidell made us feel like he had all the time in the world to speak to us. He answered every question and gave us confidence in our decisions. He made sure we had a way to contact him, and he made us feel like it was not a burden to reach out,” Katie says.

Claire’s laryngomalacia was more severe than most. Her condition was making it difficult to breathe without struggle or eat enough to gain adequate weight.

“Laryngomalacia is the most common cause of stridor in infants. It is usually not concerning because kids with laryngomalacia often breathe and eat just fine, and they tend to grow out of it in the first year. But a small number of children need surgical intervention,” says Dr. Sidell.

Breathing easy after a simple airway surgery

Dr. Sidell recommended a surgical procedure called a supraglottoplasty. Despite its long name, it is a fairly simple procedure involving trimming excess tissue to make room for air to pass through the larynx and into the trachea. Claire was given a surgery date, but Dr. Sidell bumped it up because her stridor continued to get worse.

Claire in the hospital

“When Claire was being wheeled into surgery, people said, ‘Oh wow. That’s really loud.’ We could hear her in the waiting room. But when we went to see her afterwards in the intensive care unit, we couldn’t hear the stridor anymore. There was an immediate ease in her breathing,” Katie says.

The Aerodigestive and Airway Reconstruction Center at Stanford Children’s is one of the busiest pediatric airway centers in the United States. The center provides multispecialty, coordinated care for a range of conditions affecting the airway, esophagus, and upper digestive tract.

“We see a large number of children each year for laryngomalacia. Because we tend to care for kids with more severe or complex laryngomalacia, a higher number of those children need surgery, approximately 20% to 30%,” Dr. Sidell says.

A supraglottoplasty takes less than 15 minutes in the operating room and is done under general anesthesia. It is performed through the mouth, so no incisions are made. Most children go on to lead completely normal lives and eat, drink, and grow with ease.

“Claire’s surgery went exactly as expected. The surgery made a dramatic improvement in her breathing, and she’s doing very well. She had a very typical outcome,” Dr. Sidell says.   

The end of stridor

Claire went home the next day. She was given some anti-reflux medication to help her cope with swallowing more food than she was used to being able to swallow, but Katie is confident that she won’t need the medication soon.

“Honestly, the surgery fixed it. In theory, this is the last time we will have to deal with it,” she says.

The Bridge family

Katie and Ryan were so impressed with the care they received at Stanford Children’s that they gave Dr. Sidell a five-star review in a survey from the Pediatric Otolaryngology (ENT) clinic. When asked why she had given such a rave review, Katie named his attentiveness, ease of access, and high level of care.

“Doctors have a lot on their plates these days, so to have Dr. Sidell stop and give us his presence and do that continuously throughout our infant’s care was incredible,” Katie says. “He’s kind, genuine, and thoughtful.”

As a father himself, Dr. Sidell understands how scary it is when your child needs care immediately. It’s why he shares his contact information and guides parents each step of the way through care—a trait that reflects the culture of care among doctors at Stanford Children’s.

“We take care of these babies the same way we would want others to care for our own kids,” Dr. Sidell says. “Katie and Ryan were honest about their apprehension and fears, and they were not afraid to ask questions. Knowing that they would call me if a problem or question came up was an integral part of Claire’s success. In my opinion, giving parents a direct line to me makes my job easier—not harder.”

Growing well and sleeping soundly

Today, Claire is 4 months old. The family enjoys watching Stanford University games (Katie works for Stanford Athletics, and she and Ryan are both serious volleyball players) and going on long walks and hikes. The Stanford Dish Loop Trail is one of their favorite spots.

“Claire is waking up to the world. She’s a happy, calm baby. She’s grabbing at toys and studying them with curiosity,” Katie says.

Best of all, Claire is breathing easy. And the whole family is sleeping through the night. 

Learn more at aerodigestive.stanfordchildrens.org.

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A 'CROAKY voice' that persists for longer than three weeks could be a sign of a deadly cancer.

It's one of several symptoms that can emerge when you have cancer of the voice box, otherwise known as laryngeal cancer.

Head and neck cancers are responsible for over 4,000 deaths a year in the UK


Head and neck cancers are responsible for over 4,000 deaths a year in the UKCredit: Alamy

Head and neck cancers are responsible for over 4,000 deaths a year in the UK.

And there are over 12,000 cases a year, so it's important to know the signs of the disease.

Laryngeal cancer, which develops in the voice box, is a deadly cancer that affects the neck.

As with all types of cancer, the earlier it's spotted, the more likely treatment will effective.

So if you notice any worrying symptoms, it's important to see your GP as soon as possible.

In the event of an emergency, always call 999.

The NHS have said there are six other key symptoms of laryngeal cancer to look out for:

  1. pain when swallowing or difficulty swallowing
  2. a lump or swelling in your neck
  3. a long-lasting cough or breathlessness
  4. a persistent sore throat or earache
  5. a high-pitched wheezing noise when you breathe
  6. in severe cases, difficulty breathing

Other signs also include: bad breath, unintentional weight loss, or fatigue (extreme tiredness).

When to see your doctor

You should see your doctor if you:

  • have a hoarse voice for more than 3 weeks
  • have lost 4 to 5 kg (10lbs) or more in a short time and you are not dieting
  • are short of breath or have a cough that doesn't go away, or your breathing becomes noisy (stridor)
  • have pain or difficulty swallowing
  • have any other symptoms that are unusual for you or that don't go away

Treatment options

The main treatments for laryngeal cancer are radiotherapy, surgery, chemotherapy and targeted cancer medicines.

Radiotherapy can be used to removed cancerous cells if the cancer is caught early enough.

If the cancer is more advanced surgery to remove part or all of the larynx, along with radiotherapy and chemotherapy can be used.

If you have part of your larynx removed you won't be able to speak or breathe like you usually do.

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Postextubation use of certain modes of noninvasive respiratory support was associated with fewer incidents of extubation failure in critically ill children, a meta-analysis found.

Compared with conventional oxygen therapy, both continuous positive airway pressure (CPAP; OR 0.43, 95% credible interval [CrI] 0.17-1.0) and high-flow nasal cannula (HFNC; OR 0.64, 95% CrI 0.24-1.0) appeared more effective at reducing extubation failure, the requirement for reintubation within 48 to 72 hours of removing the artificial airway, reported Narayan Prabhu Iyer, MBBS, of the University of Southern California, Los Angeles and coauthors.

As for treatment failure -- defined as reintubation or use of another mode noninvasive respiratory support -- CPAP (OR 0.27, 95% CrI 0.11-0.57) and HFNC (OR 0.34, 95% CrI 0.16- 0.65) were both more effective compared with conventional oxygen therapy, the meta-analysis published in JAMA Pediatrics found.

While not statistically significant, bilevel positive airway pressure (BiPAP) trended toward being a numerically better treatment option for preventing treatment failure and extubation failure in the pediatric ICU (PICU).

Out of the various types of noninvasive respiratory support, CPAP treatment had the highest probability of being the best option for minimizing extubation failure and treatment failure.

However, both CPAP and BiPAP were associated with an approximately 3% increase in nasal injury and abdominal distension.

Researchers noted that no method of noninvasive respiratory support has been proven to be the "optimal method;" its use varies in different settings as rescue or planned prior to extubation. Moreover, it is unclear which critically ill children are likely to need planned breathing support, if they need it at all.

Martin Kneyber, MD, of the University of Groningen, the Netherlands, commented that the present meta-analysis did not include individuals who did not require postextubation respiratory support.

"Now, the most challenging aspect of all of these studies is that they have included many patients in whom pre-emptive use of non-invasive respiratory support post-extubation was ordered. This is not my practice; I extubate 99% and wait and see," he told MedPage Today in an email. "So, in my view, future studies should really identify the subset of patients that benefits from post-extubation non-invasive respiratory support."

Jeremy Loberger, MD, of the University of Alabama, Birmingham, however, commented that CPAP has been particularly successful in infants 6 months old or younger, especially when it is included as part of extubation strategy right from the start. "I've seen greater success with supporting them more (with HFNC, CPAP, or BiPAP) at the start rather than trying to rescue them when they show signs of failing on conventional oxygen therapy," he said.

For the meta-analysis, Iyer's group included nine randomized clinical trials featuring 1,421 pediatric patients. Participants in the studies were critically ill, born no earlier than 37 weeks gestational age, and were supported with mechanical ventilation for over 24 hours followed by postextubation noninvasive respiratory support. Most were under 48 months old.

Participants with certain noncardiac congenital abnormalities were not included in the meta-analysis, so the report may have limited applicability to older pediatric patients and those coming out of heart surgery, cautioned Hunter Wilson, MD, of Children's Healthcare of Atlanta, who was not involved with the meta-analysis.

"In my experience older patients often have more robust respiratory mechanics than younger patients and so extubating an older cohort of patients to CPAP may be too conservative and actually prolonged hospital length of stay and need for sedation, etc.," he told MedPage Today.

"I think it will be difficult to clearly translate these findings to the population of patients who are extubated following heart surgery. There are some additional ways in which positive pressure can support heart function and so it may be difficult to translate findings from a general PICU population to this population in particular," Wilson added.

Other limitations to the meta-analysis include low-certainty results due to bias in some included studies and a lack of data on outcomes or resource utilization.

"When choosing a NRS [noninvasive respiratory support] mode, considerations of equipment availability, associated costs to patients and the health care system, and the need for a high level of nursing care are also important," Iyer and colleagues wrote. "These factors vary across health systems and geographic regions and are likely to have an impact on the relative efficacy of different NRS modes."

  • author['full_name']

    Elizabeth Short is a staff writer for MedPage Today. She often covers pulmonology and allergy & immunology. Follow


This study was supported by funding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development; the National Heart, Lung, and Blood Institute of the National Institutes of Health; and the Department of Pediatrics at Indiana University School of Medicine.

Iyer reported relationships with the Eunice Kennedy Shriver National Institute of Child Health and Human Development and the National Heart, Lung, and Blood Institute.

Primary Source

JAMA Pediatrics

Source Reference: Iyer N P, et al "Association of extubation failure rates with high-flow nasal cannula, continuous positive airway pressure, and bilevel positive airway pressure vs conventional oxygen therapy in infants and young children: A systematic review and network meta-analysis" JAMA Pediatr 2023; DOI: 10.1001/jamapediatrics.2023.1478.

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  • 'I don't know where I am,' said Kenya from her hotel bed during the girls trip to Birmingham, Alabama, while calling 911 for an ambulance 
  •  'I'm dizzy and I'm having a hard time breathing,' Kenya added. 'I'm just recovering from COVID and I don't know what it could be now'
  •  'I woke up feeling the weight of everything that I have been through in the last few weeks,' Kenya told the camera. 'I'm feeling numbness or pain in my left arm'

Kenya Moore was rushed to the hospital by ambulance after complaining she was having difficulty breathing on Sunday's episode of The Real Housewives Of Atlanta.

'I don't know where I am,' said Kenya, 52, from her hotel bed during the girls trip to Birmingham, Alabama, while calling 911 for an ambulance.

'I'm dizzy and I'm having a hard time breathing,' Kenya added. 'I'm just recovering from COVID and I don't know what it could be now.'

In a confessional, Kenya provided more background on her illness that struck her after Marlo Hampton banged on her door.

'I woke up feeling the weight of everything that I have been through in the last few weeks,' Kenya told the camera. 'I'm feeling numbness or pain in my left arm.'

Difficulty breathing: Kenya Moore was rushed to the hospital by ambulance after complaining she was having difficulty breathing on Sunday's episode of The Real Housewives Of Atlanta

When the ambulance arrived and paramedics entered Kenya's room, Shereé Whitfield, 53, opened her hotel room door and saw them. Sheree then called Marlo, 47, Monyetta Shaw-Carter, 42, Courtney Rhodes, 48, to come to her room and told them that an ambulance took Kenya to the hospital.

'She was having trouble breathing,' Sheree said.

Monyetta started crying while thinking about losing her mother. Marlo said they should say a prayer for Kenya. Sheree FaceTimed Kenya who told them from the hospital that she had a fever of 102 and was still waiting for the results of other tests.

'We argue and we're fighting about stupid s***, and this is real stuff in the hospital,' Marlo said.

Marlo reached out her arms to give Monyetta a hug and apologized for what happened the previous night. Monyetta told Marlo that she came very close to hitting her with the door. 

Sheree said the door was very heavy. Marlo said they should just respect each other but she would take accountability. Marlo called Sanya and told her what happened.

Marlo later tried to send Kenya flowers but the hospital said she was already checked out.

'Look I thought this was going to be a fun girls trip but it was a big a** disaster,' Marlo said in a confessional.

Ambulance ride: The former Miss USA winner was on a rolling gurney as she was loaded into a Birmingham Fire & Rescue ambulance
Really sick: Kenya said that she couldn't even call 911 because she was so sick
Quick response: First responders quickly came to Kenya's hotel room
Felt numbness: 'I woke up feeling the weight of everything that I have been through in the last few weeks,' Kenya told the camera. 'I'm feeling numbness or pain in my left arm'

The season 15 episode titled 'Drama for Yo Mama' started with the women banging on Kenya's hotel room door after Kenya went to bed early and refused to come out.

'Who the f*** are you stop being disrespectful with your broke ass,' Marlo said.

'I'm calling the f***ing police if you knock on my godd*** door again!,' Kenya said.

'Child, I'm leaving,' Marlo said.

Monyetta tried to defend Kenya.

'Marlo and Monyetta are both the type who have to have the last word,' Shereé said. 'It's like playing rock, paper, scissors with two rocks.'

Checking in: Shereé Whitfield heard the commotion and checked in on Kenya
Last words: 'Marlo and Monyetta are both the type who have to have the last word,' Shereé Whitfield said in a confessional. 'It's like playing rock, paper, scissors with two rocks'

When they got to the lobby, it appeared that Marlo tried to close the door in Monyetta's face.

'She tried to close the door in somebody's face with force,' Monyetta said. 'Girl, does she want to go back to jail?'

Kenya then called Monyetta and said that Marlo was a 'snake.'

'Girl, I'm done,' Monyetta said.

Kenya said she would just feel better if the people who weren't in her core group just went home. 

Sanya Richards-Ross, 38, took the phone and said she just wanted to know what they were doing in Birmingham because she had work in the morning.

'Sanya, don't come back,' Kenya said. 'It's okay.'

Sanya packed her bags and left. Kenya finally revealed to Sheree that they weren't there for just the game but that she was performing at halftime.

Disastrous trip: Sanya Richards-Ross, 38, took the phone and said she just wanted to know what they were doing in Birmingham because she had work in the morning
Early exit: 'Sanya, don't come back,' Kenya said. 'It's okay'

'Kenya, that's all you had to say,' Sheree said.

'This is a once in a lifetime opportunity!' Kenya said.

Kenya said she just wanted the other women to go home, calling them 'bad energy.'

Sanya called Marlo and told her that Kenya told her to leave.

'I just texted her ''you are a rude, selfish MF! Seek help! Rude b****'',' Marlo said. 'She's Kanye West. She needs help.'

Back in Atlanta, Drew Sidora, 38, got released from the hospital after being treated for the flu. 

Kandi Burruss, 47, and her husband Todd Tucker discussed his new project, a movie called The Pass. 

Feeling better: Back in Atlanta, Drew Sidora, 38, got released from the hospital after being treated for the flu
Catching up: Kandi Burruss, 47, and her husband Todd Tucker discussed his new project, a movie called The Pass

Kandi said she didn't go on Kenya's trip because she was getting an award at the Ebony Power 100. They also discussed Kandi's mother Mama Joyce making constant jabs at Todd.

'He's been putting up with it all these years and he's just tired,' Kandi said in a confessional. 'I need to fix it.'

Sheree went to check on Kenya back at her house who told her that the doctors did the chest x-ray but couldn't find anything abnormal but told her she had the flu.

'I don't remember everything,' Kenya said. 'I just remember Marlo kicking at my door, being angry.'

Sheree said she couldn't defend Marlo's behavior. Sheree also shared that she was dealing with her fibroid health issues and was trying to avoid having surgery.

'Everyone I know who had surgery for fibroids, they keep coming back,' Sheree said.

Sheree said she was trying to shrink them the holistic way.

'If you have surgery then you can't have sex for six to weeks,' Sheree said in a confessional. 'Where you doing that at?'

House call: Sheree went to check on Kenya back at her house who told her that the doctors did the chest x-ray but couldn't find anything abnormal but told her she had the flu
Foggy memory: 'I don't remember everything,' Kenya said. 'I just remember Marlo kicking at my door, being angry.'

Kandi had her mother Mama Joyce over to talk about the negative things she kept saying about Todd at BravoCon. Kandi told her the comments went viral.

'You are constantly dragging him in public,' Kandi said. Kandi said that she was about to celebrate her ninth year wedding anniversary with Todd.

'At this point, it's getting out of hand,' Kandi said. 'You've got to stop.'

'I need my mother to understand how much Todd means to me and that this marriage is solid and leave it alone,' Kandi said in a confessional.

'The guy you married was like a meek and humble little person,' Mama Joyce said. 'Now he's like a George Jefferson little guy. '

'You are tripping,' Kandi said.

Kandi told her to stop nitpicking Todd.

'You love your man not taking out the trash, go to strip clubs, whatever,' Mama Joyce said.

Candid conversation: Kandi had her mother Mama Joyce over to talk about the negative things she kept saying about Todd at BravoCon

'We go to strip clubs together,' Kandi said. 'I am not threatened by a stripper at the strip club.'

Kandi suggested that they go to counseling together and Mama Joyce agreed.

'I think the therapist is going to need therapy after hanging out with us,' Kandi said in a confessional.

Kenya met up with Sheree and Drew to get IV vitamin drips. Kenya told them that she missed her run-in with Marlo in Birmingham and Drew shared about her run-in with Marlo and how she had been angry that Kandi hadn't been more compassionate to the shooting of her nephew who had worked as a chef for her. Sheree said they should make a pact to keep up the positive energy.

'I'll be my positive self,' Kenya said. 'I can be very forgiving to anyone. I think the key is you acknowledge, apologize, and change behavior. '

The show then flashed to three days later with Kenya calling Kandi to tell her about Marlo's comments regarding her nephew. Kandi got visibly upset

'I'm going to tell you what the f***,' Kandi screamed at Marlo.

Go together: 'We go to strip clubs together,' Kandi said. 'I am not threatened by a stripper at the strip club'
Heated confrontation: 'I'm going to tell you what the f***,' Kandi screamed at Marlo

'Her character went out the window when she slashed all those people's faces,' Kenya said.

'Go cry to your momma,' Marlo shot back at Kenya, who was abandoned by her mother.

'The only reason I'm crying right now is because I can't f****ing choke your a** b****,' Kandi said.

The Real Housewives of Housewives of Atlanta will return next Sunday on Bravo.

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A HIDDEN DEFECT: Alex joined two friends on a cross-Snowdonia trek to raise funds for the British Heart Foundation after undergoing open heart surgery (Image: Collect/PA Real Life)

A runner whose silent heart attack revealed a defect that put him at risk of premature death has now raised more than £50,000 by trekking 100 miles. A year after the attack, Alex Roth, 56, a media executive, tackled the distance across Snowdonia to raise funds for the British Heart Foundation (BHF).

Alex believed he was having an asthma attack as he had trouble breathing while running in January 2022, but he had suffered a heart attack, and his life was at risk due to an unrelated heart defect. Alex lives with his wife, Erin, 57, a school chairperson, and has three children, Jack, 26, Max, 25, and Helen, 20.

He would run 35 miles a week on average, rain or shine, summer or winter, and was in good shape, having never smoked and had drank little alcohol, so he never thought he would be someone at risk of a heart attack. Alex first experienced breathing problems in 2018 but became more laboured in January 2022.


Alex said: "Afterwards, I kept saying to my wife, 'I don't understand how this could possibly happen to me', but I've now realised that being fit and looking after yourself is not a way to avoid these things. You are still at risk of things like heart disease and have to be aware of the signs; however, being healthy is a good way to prepare to deal with something like this when it happens.

"If I hadn't been in good shape, then things could have ended up a lot worse than they did. I've always considered myself to be healthy, but I started having trouble breathing while running, which I assumed was a bit of asthma. I couldn't run four miles without taking a break, and even then, I continued to feel discomfort in my throat."

Alex had suffered a heart attack with no chest pain or other common symptoms, and when he explained the 'strange' feeling in his throat, his doctor referred him to a cardiologist. They investigated his heart for damage and realised he had a mitral valve defect, which occurs when the mitral valve becomes too floppy, leaks or does not open wide enough.


MOUNTAIN WALK: Alex, Jim and Hayden trekked through Snowdonia between May 8 to 12, 2023 (Image: Collect/PA Real Life)

He said: "The doctor recognised that it was a cardiac issue and told me that I was not permitted to do any exercise of any form until I had seen the specialist. But not realising how serious this was, I woke up the next morning and told my wife I was going for a run.

"I just didn't understand and had no concept of heart disease and what it looked like. When I saw the cardiologist, he explained that, based on blood tests, I had had a heart attack at some point in the prior two weeks. I realise now, looking back, that running after having had a heart attack was actually a very dangerous thing to do.

"The defect leads to premature death, so the irony is that the heart attack probably saved my life because if I'd not had it, then I wouldn't have realised I was living with a severe heart defect."


A QUIET PINT: Naming the challenge Eryri 100, Alex set off on the 100-mile trek with two friends, Hayden and Jim (Image: Collect/PA Real Life)

Alex required open heart surgery to repair the valve, so he was only allowed to walk for exercise, walking around 35 miles a week until he went under the knife last year. He said after leaving surgery, he felt really weak, despite being 'strong going into it', and was depressed, but he decided to set goals for himself.

Alex ran 10km in February 2023 after regaining his strength before taking on a half marathon, but he had to stop after completing eight miles. But Alex has found a new passion for walking and decided to raise funds for BHF with two friends in Snowdonia between May 8 to 12, naming the challenge the Eryri 100 after the Welsh name for Snowdonia.


He said: "It was harder than I expected it to be but, in many ways, Eryri 100 was a microcosm of my entire illness and recovery. I could tell that my fitness is not what it used to be, and the trek was super challenging, but I did it with the support of family and friends.

"It was quite emotional. I think the most touching part was after the fourth day, which was the toughest of all the five days, we arrived at a pub, and when we got there, so many friends and colleagues had come from London to join us.

"My wife, Erin, was there, and I just couldn't believe that everyone had come out to support us on the last day of the hike."

Alex, from London, has now raised more than £54,000 for BHF.

To donate, visit the website here.

What are your thoughts on Alex's challenge? Let us know in the comments below.

Get all the latest news, updates, things to do and more from your local InYourArea feed.

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Oxygen Wellbeing at West Down Farm in Corton Denham, reached out to help after learning of the Dorset Cancer Care Foundation&#x002019;s (DCCF) wish to help more people in the north of the county &lt;i&gt;(Image: Oxygen Wellbeing)&lt;/i&gt;

Oxygen Wellbeing at West Down Farm in Corton Denham, reached out to help after learning of the Dorset Cancer Care Foundation’s (DCCF) wish to help more people in the north of the county (Image: Oxygen Wellbeing)

A DORSET clinic which offers Hyperbaric Oxygen Therapy hosted a coffee morning to help a Dorset cancer charity.

Juliet and Steve Thornton, owners of Oxygen Wellbeing in Sherborne, reached out to help after learning of the Dorset Cancer Care Foundation’s (DCCF) wish to help more people in the north of the county.

Steve is a retired Metropolitan firearms officer and the couple set up the business largely because of Steve’s ongoing work with people from blue light and military backgrounds who suffer from Post-Traumatic Stress Disorder (PTSD).

Hyperbaric Oxygen Therapy - or HBOT - sees users breathe 95 per cent oxygen within a pressurised hyperbaric chamber. The drug-free therapy is used to help the body heal from injury or surgery and relieve pain and reduce inflammation in conditions such as arthritis, long covid and multiple sclerosis.

Juliet said: “We are also privileged to be helping some local cancer patients, so, when we heard that the DCCF was trying to publicise its work in and around Sherborne we were keen to help.”

The DCCF helps Dorset people and their families who are experiencing financial hardship because of a cancer diagnosis.

The charity’s non-refundable grants are used by recipients to pay for costs such as travel to and from their hospital treatment, household costs, childcare and respite breaks.

Funded entirely by supporters and events, since 2010 the DCCF has given over £663,000 to 760 individuals and organisations.

Oxygen Wellbeing’s DCCF Coffee Morning raised over £135.

Steve said: “We were blessed with great weather and great company and as well as raising funds for the charity, Jaz and Meryl from the DCCF were able to share valuable information with our visitors. We also had a raffle which was kindly supported by local businesses.”

Jazmine White, charity manager for the DCCF, said: “We were delighted when Juliet and Steve offered to raise money and awareness for the charity.

“The DCCF is making a real difference to the lives of people with cancer in the east of the county and we would like to help people from all over Dorset.

“We know there are many people who would benefit from our help, and perhaps would also like to fundraise for us. So, please get in touch.”

The DCCF can be contacted via phone 07593 890879, via email at [email protected] or online at www.dccf.co.uk

Oxygen Wellbeing can be contacted on 01962 34996, or via [email protected]


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Since mid-2021, global concerns appear to be focusing on scourges other than the Covid-19 pandemic. This disease could nonetheless go through seasonal resurgences as do other respiratory infections, especially the flu. Covid-19 is transmitted mainly through contact with soiled, previously contaminated objects (also referred to as “fomites”) and through the transport and dispersion of particles emitted by infected people. In this regard, it has been established that virions, the extracellular form of viruses, are present and pathogenic in liquid particles produced by infected people when they sneeze or cough, but also when they speak or simply breathe. Virions are found in the sputum of symptomatic people, but also in that of asymptomatic people, who can unknowingly transmit the infection to others who, in turn, will be unaware that they have been contaminated. Airborne transmission of infectious agents carried in liquid particles of different sizes is discussed later in the introduction. It raises concerns, especially since it is not specific to Covid-19; indeed, it is common in many other respiratory diseases such as the other severe acute respiratory syndromes (SARS), Middle East respiratory syndrome (MERS) or the many types of influenza (H1N1) and their variants.

The sizes of particles expectorated depend on the dissemination event, and even on the human behind it (in other words, two people do not produce the same spectrum of liquid particles when breathing or coughing). The range of sizes extends over several orders of magnitude (from 0.1 to 1000 µm in aerodynamic diameter). A cut-off diameter (around 5 to 10 µm) separates the finer particles, which are “real” aerosols sustainably suspended in the air, from the larger particles, which, according to the conditions of their emission, either settle almost immediately on accessible surfaces or behave like projectiles. In this article, we consider particles of discrete sizes and use the word “droplets” for particles whose diameter is either 1 or 10 µm, whereas the word “drops” refers to particles with a diameter of either 100 or 1000 µm. Also, the word “diameter” implicitly means “aerodynamic diameter.”

On a global level, not all countries agree on the measures to be taken in the face of Covid-19: some apply strict testing and lock-down measures, while others put up with the presence of the disease as long as it remains limited. However, the World Health Organization (WHO) like the health institutions of many countries ended up advocating the mask use as valuable for limiting the dissemination of virions exhaled by infected people during respiratory events. Mask use was systematically made compulsory during the acute phases of the pandemic. It has persisted in places such as hospitals, pharmacies and public transport. Even though mask use currently remains compulsory only in certain countries, it will clearly become advisable again in the event of a Covid-19 resurgence, wherever it may occur.

In a previous article1, we attempted to fully demonstrate the value of Computational Fluid Dynamics (CFD) to account for the three-dimensional space and time dispersion of particles emitted by people infected with diseases leading to expectoration of pathogens such as virions. To illustrate our point, we studied the risk of Covid-19 transmission among public transport passengers. We created a twin experiment by reproducing the numerical mock-up of a commuter train car in which human manikins were placed. We assumed that an infected individual emitted droplets and drops while breathing and during coughing episodes. The particles were transported by the ventilation system of the coach and exhibited totally different aerodynamic behaviour depending on whether they were droplets (which perfectly followed the streamlines) or drops (which separated from the carrier fluid by their inertia and tended to sediment in the immediate vicinity of the spreader). In addition, the cough was characterised by the initial momentum given to the emitted particles. While the droplets adapted very quickly to the flow around them, this was not the case for the largest drops, which adopted a ballistic behaviour. This phenomenology was highlighted in our three-dimensional simulations, which examined the turbulent flow within the coach and the dispersion of particles of different sizes (using an Eulerian approach and a Lagrangian approach that led to similar results).

While our article1 enabled us to present and validate our CFD model, it was limited to the case in which passengers did not wear masks. This situation corresponds to what prevails today in places where the Covid-19 outbreak seems to be behind us, at least in some countries. When the epidemic was active, however, many governments mandated the wearing of masks on public transport; this remains the case in some parts of the world and could become widespread again in the event of a resurgence of Covid-19 or other respiratory diseases. In addition, we thought it would be interesting and useful to attempt to carry out CFD simulations featuring mask use by passengers. We were particularly interested in knowing if mask use could effectively reduce the dissemination of virions in a public space such as a railway coach. This led us to undertake simulations involving, once again, a twin experiment in a railway coach, this time with passengers wearing masks and, among them, one passenger assumed to be infected with the Covid-19 disease. In the simulations reported in this article as in the previous one, the liquid particles are assumed not to evaporate and we study their spatial and temporal distribution around the human manikins occupying the railway coach.

This new research article is structured as follows. We first present a review of the literature: on one hand, we take stock of what is known or still debated at the end of 2022 regarding the transmission of the SARS-CoV-2 virus; on the other hand, we examine the influence of mask use on the droplets and drops produced by an individual breathing and coughing. As there are many types of masks, special emphasis is placed on the surgical mask, which is very widespread due to its particularly low cost. We then devote a part of the article to the results of our modelling and simulation work. First we consider the head and bust portion of a human manikin, which is immersed in a motionless atmosphere; this allows us to examine the situations in which the manikin wears a tight-fitting mask, a loose-fitting mask, or no mask at all. We next present results obtained with complete human manikins wearing masks and placed in a commuter train, with one of the passengers being infected with the Covid-19 disease. In the next section of the article, we present a general discussion about the results obtained and the perspectives offered by our numerical approach in terms of scientific developments and operational applications. Part of the article is devoted to the methods used in the numerical study. In particular, we explain our choices regarding the production of droplets and drops, depending on whether the manikins wear more or less well-fitting masks, and regarding the aerodynamic conditions in the railway coach. We also present the CFD tool implemented in the study, as well as the computational resources and the associated computation times.

Aerial transmission of the SARS-CoV-2 virus and other pathogenic respiratory agents

The mode of transmission of the SARS-CoV-2 virus (which causes Covid-19) was intensely debated in 2020, as the results were to determine the healthcare responses needing to be made. In July 2020, the WHO2 recognised that the SARS-CoV-2 virus could be transmitted from person to person through the air. This virus is known to be carried in liquid particles exhaled through the mouth and the nose, particularly when coughing, sneezing, speaking, singing or breathing3. These particles, whose exact chemical composition remains unclear, contain multiple virions of about 100 nm in size4. The combination of entrainment by the airflow, particle inertia, gravity and evaporation determines the evolution of the exhaled particles.

Historically, particles carrying virions have been separated into two categories according to their aerodynamic behaviour5, on the grounds that this dichotomy should be a source of guidance for national health authorities and the WHO. We therefore make a distinction between drops – “visible” particles with a diameter greater than about 5 to 10 µm, which fall under the effect of gravity without having time to evaporate, finally settling on exposed surfaces (fomites) – and droplets, presenting a diameter of less than 5 to 10 µm, which evaporate more or less rapidly to a dry nucleus and remain suspended in the air in the form of an aerosol6. The droplets are carried by the airflow, which depends on the local ventilation conditions7. They are likely both to cause contamination at longer distances and to penetrate deeper into the respiratory tract in comparison to drops8,9. The threshold of 5 to 10 µm that is usually considered has been discussed and questioned during the pandemic3, and it is clear today that all classes of particles must be taken into account, as well as the two modes of transmission at short and long distances10.

The number and size of particles exhaled by a spreader are highly variable. The overall exhalations of a human being are known to contain particles between 0.1 and 1000 µm in aerodynamic diameter, i.e. five orders of magnitude11. Symptomatic and asymptomatic carriers do not a priori produce the same number or the same size of viral particles. In addition, symptomatic carriers do not necessarily excrete higher viral-load drops and droplets than do asymptomatic infected people12. There are also people called “super-spreaders.” It has been shown, for example, that some individuals produce seventeen times more droplets during a cough compared to other individuals13. It has also been shown that the viral load of the particles changes according to the stage of the disease.

The proportion between exhaled drops and droplets is variable and still subject to debate, as is the potential for aerosol contamination. For example, trials7 have shown that 20,000 particles between 0.8 and 5.5 µm, along with 100,000 virions, are emitted every minute during speech. In a series of analyses, aerosols smaller than 5 µm have been shown to contain more SARS-CoV-2 virions than do particles larger than 5 µm14, while other findings tend to go the other way13. The number of exhaled particles varies depending on whether we consider a low-frequency event or a cyclic event. For example, a sneeze can produce around 10,000 particles15, a cough around 10 to 100 times fewer16 and breathing or speaking a minimum of 50 particles per second, but since breathing and speaking are recurrent phenomena, they are probably ten times more important in contamination than coughing or sneezing17.

Experimental work13 makes it possible to assess both the number of particles produced during coughing and speaking and the corresponding viral load. For instance, this work mentions that during a cough, 98% of the volume of particles is made up of drops of 100 to 1000 µm, with more than 20 106 droplets (with a diameter of less than 10 µm) being produced in a single cough. By comparison, the experiment proposed for speech (“stay healthy” pronounced 10 times) produces more than 7 106 droplets. The authors use a viral load estimate of 7 106 virion copies per millilitre of respiratory sample. Measurement of the volume of the cough droplets shows that it has about 104 copies, i.e. one in 2000 droplets contains at least one virion.

Finally, it should be noted that the diameter of the particles varies in the air under the effect of evaporation. The final particle diameter depends on many factors such as initial size, relative humidity, temperature, ventilation flows and residence time11. For example, an average particle size of 2 to 3 µm can be obtained for an initial size of 10 µm18.

While numerous scientific works carried out during the Covid-19 pandemic have supplemented the knowledge acquired over a long period of time on the transmission of infectious agents, many questions about the SARS-CoV-2 virus are not yet clearly resolved, such as the relative contagiousness of drops and droplets according to their diameters, the “minimum dose” to risk contamination, the number of virions exhaled by infected people or the evolution of the pathogenicity of the virions embedded in evaporating drops and droplets.

Use of surgical masks and their effect on aerial transmission

The surgical mask is a single-use respiratory mask whose purpose is to limit to the immediate environment the spread of bacteria and viruses exhaled from the respiratory tract (mouth and nose) of the wearer. Its main purpose is to filter the largest respiratory drops (above a few tens of micrometers). Originally, this type of mask was worn by healthcare professionals during surgery to protect the sterile operating field and the patient receiving care. It is also worn by patients with a disease whose contagious agent is airborne.

When used correctly, a surgical mask quite successfully contains the dispersion of respiratory drops produced during a sneeze or a cough. It is commonly accepted to be an effective device for blocking drops projected by the wearer and measuring several tens of microns. It has been shown to greatly limit the transmission of airborne viruses (influenza, coronavirus, etc.) by infected people19. That said, it is not very effective in stopping the transmission of fine aerosols smaller than 5 µm20, and its effectiveness depends on its design, the materials used in its manufacture, its dimensions and its fit on the face.

Above all, the surgical mask protects the individuals surrounding the person wearing it – but the wearer is also protected from projections of drops, though it is unknown to what extent exactly. The protection provided by a surgical mask during inhalation is real, but unquantified and extremely variable. Such a mask is not designed to protect the wearer from inhaling airborne bacteria or viral particles.

Generally speaking, filtering facepiece (FFP) masks are personal respiratory equipment defined by standards such as EN 14921 in the European Union. This type of mask protects the wearer of the mask against the inhalation of particles in suspension in the air (average aerosol diameter of 0.6 μm) and drops of larger diameters. Leaks inside the mask are also standardised. There are several types of masks – FFP1, FFP2 and FFP3 – categorized by their filtration of aerosols with an average diameter of 0.6 µm (respectively 80%, 94% and 99%) and their degree of leakage towards the inside of the masks (respectively less than 22%, 8% and 2%).

The surgical mask is not a filtering respiratory device and cannot be certified as such. To be approved, however, it must meet standardised criteria based on bacterial filtration efficiency (BFE; during exhalation only) and splash resistance. For instance, in the EU, types I and II correspond to masks with, respectively, BEF > 95% and BEF > 98% of an expired aerosol with an average diameter of 3 µm, while type III is like type II but is also resistant to splash. There exists a test protocol for evaluating BFE22 whose presentation would be beyond the scope of this article, as would be the description of all standards that apply to masks intended for workers (for instance, medical staff) or the general public. The reader is referred, for example, to an Internet site23 that provides an interesting compilation of the standards that apply in the USA, the EU, China, Japan, South Korea and elsewhere.

Particle filtration efficiency during exhalation

Several authors have studied the filtration efficiency of surgical masks for various particle sizes, including fine particles. In one experiment24, different types of masks were tested with the assumption that they were perfectly fitted, i.e. without leakage between the mask and the wearer’s face. Drops with a diameter greater than 10 µm were generally filtered by the different masks, as were particles with a diameter less than 200 nm, due to the Brownian effect. Still, none of the masks tested, apart from FFP2 N95, could filter 100% of the droplets of intermediate size whose diameter was between 1 and 5 μm. In this experiment, even with a perfectly tight fit, aerosol leakage through the surgical mask represented 0.1% to 0.2% of the exhaled particles. Another experimental work25 involving different types of perfectly fitting surgical masks gave even poorer overall aerosol filtration efficiency results for surgical masks, with about 50% of particles with a diameter between 1 and 8 µm being retained.

In practice, leakage can be very significant at the wearer’s face, because the mask lets a large quantity of air pass around its perimeter. For instance, the presence of fog on eyeglasses shows that a good deal of air is exiting directly without passing through the filter screen. The problem of leaky surgical masks is not new, and it has often been studied already, at least qualitatively, leading to wear and adjustment recommendations for healthcare personnel26. A few precautions can limit the rate of leakage: these include a knot in the ear loops, a well-adjusted nose clip or the use of a cloth mask over the surgical mask, as per CDC recommendations27.

More recently, the problem of leakage from surgical masks has been presented experimentally in a relatively large number of scientific publications. For instance, an experimental reconstitution28 of the cough of a human manikin showed that only 56% of aerosols between 0.1 and 7 µm were filtered by a surgical mask, due to leaks around the edge of the mask. The filtration percentage increased to 77% with adjustment by side knots and the use of a nose clip, and even to 85% when the surgical mask was covered with a cotton mask.

Detailed CFD simulation work carried out on the subject in 2021 by the Riken Scientific Research Institute (Japan)29 also showed that the fraction of aerosols passing through different types of fabric masks without being filtered was larger than 70% with a variable fraction of aerosols leaking through the spaces between the wearer’s face and the mask.

Apart from its more or less effective filtration properties, a surgical mask can significantly reduce the airflow velocity during a sneeze, during a cough or within the respiratory cycle30,31,32,33,34. That said, the inhalation and exhalation phases also increase leaks on the perimeter of the mask due to “pumping” effects. Thus, the air jets resulting from these leaks can be highly turbulent and directional, which increases the effects of aerosol dispersion in the transverse directions but redirects the aerosols in directions that are a priori less problematic than a breath of air emitted directly from the mouth or nose of the wearer35,36.

It is also possible to visualise changes in exhaled airflows through density differences (due to temperature differences between the lukewarm exhalation and the ambient air) by means of the Schlieren process37. In the work cited, the authors showed that the direction and range of the exhaled airflow were modified according to the type of mask worn. Instead of passing through the filtering part of the mask, the air flows partially around the filtering part through leaks. Leakage can be two thirds of the total airflow through all parts of the mask. This fraction is much larger for surgical masks than, for example, FFP masks. The leaks between the mask and the face may be so significant that, according to the authors, the effectiveness of the masks should be considered based on the existence of secondary airflows around the perimeter of the mask, which depends on whether or not the mask is properly worn rather than on its intrinsic filtration efficiency or its ability to reduce the main airflow through the mask.

Looking beyond experimental evaluations, CFD presents the advantage of allowing precise access to airflow velocities and particle trajectories. That said, few simulations involving surgical masks and their inherent leaks have been carried out. One example is given by a CFD study38 of a human manikin wearing a surgical mask, in which the air and droplet leakage through and around the mask were evaluated for a five-second cyclical cough (with 1,008 droplets per cycle and a maximum expectoration velocity of 5 m.s−1). The numerical simulations were carried out with the Open FOAM software using an unsteady RANS approach for turbulence and a Lagrangian approach for particle tracking. The particle diameters were between 1 and 300 µm, and the filtration efficiency of the modelled surgical mask was assumed to be 91%. The authors used these simulations to identify the main locations of the leaks, evaluating the airflow velocities through these leaks to be approximately 0.2–0.4 m.s−1. The results also made it possible to estimate the relative proportions of droplets that were blocked by the mask, that passed through the mask and that escaped through leaks. The positive role of the mask, both in terms of filtration and reduced exhaled flow, was highlighted. Unfortunately, the authors did not establish a connection between the nature of the leakage and the particle diameter.

Particle filtration efficiency during inhalation

There exist no standardised data on wearer protection against incoming aerosols (that can also penetrate inside the mask by passing through the spaces between the wearer’s face and the mask). There have, however, been experimental studies published on this subject39,40,41. Between 20 and 80% of aerosols with a diameter of less than 1 µm passed through the mask, depending on its design, the number of layers, the material used for filtration and the airflow imposed through the mask. In another experimental work42, 20% to 80% of 1– to 3–µm diameter droplets passed through the mask.

On the same topic, an interesting experimental comparison43 was made for different types of masks regarding their filtration efficiency during inhalation (inward) and exhalation (outward). The aerosol diameters were between 0.04 and 1 µm in the first case, and between 2 and 5 µm in the second. The filtration efficiency of the mask was evaluated by tests on a specific test bench using a sample of the mask material (which therefore presents no leaks). In addition, the inward and outward protection efficiencies were determined using tests on manikins (accounting for leaks). For diameters less than 5 µm, the results depend on the diameters, with the exhalation and inhalation filtration efficiencies found to be between 25 and 75%. There is a significant deficiency in the effectiveness of the surgical mask for diameters below 2 µm, whether the wearer is inhaling or exhaling. Above 5 µm, the exhalation and inhalation efficiencies of the surgical mask were comparable (around 75%).

Very few CFD simulations have focused on the filtration of inhaled aerosols through a surgical mask. The study44 considers the head of a human manikin inhaling aerosols through a perfectly fitted surgical mask (with no leaks). The aerosols were between 1 and 20 µm in diameter. The filtration efficiency of the mask was set to 65% for all diameters. The originality of this study resides in its consideration of both the upper airways (nose and pharynx) and the lower airways (mouth and larynx), with the results showing that mask use clearly alters the flow near the nose and mouth. The air velocities were significantly lower and the particles entered less deeply into the respiratory tract favouring the deposition of aerosols in the upper airways (nose). Overall, wearing the mask reduced the quantity inhaled by three and five, respectively, for the 3–10 µm and 15 µm aerosols. For the aerosols of 1–3 µm in diameter, the quantity inhaled was almost the same regardless of whether a mask was worn or not.

Another publication35 presents a CFD and experimental study featuring the head of a human manikin equipped with an FFP2 mask. Even though the mask studied was not a surgical mask, this study enabled the assessment of leak sites around the perimeter of the mask and the way in which these leaks were distributed. The results indicated that, on average, leaks occurred mainly at the level of the nose (35 to 50%), to a lesser extent near the cheeks (20 to 25%) and least of all near the chin (6 to 12%).

Summary of the literature review focusing on surgical masks

A number of studies have examined the effectiveness of surgical masks, though most of them have not been carried out in the context of the Covid-19 pandemic, but instead for other infections (especially influenza). In addition, most of these studies have been experimental and solely qualitative, with different areas of focus (samples of filtering materials, masks placed on human manikins or patient cohorts). Due to differences among the protocols and the challenges involved in making the various measurements, the conclusions of these studies can be contradictory. Nevertheless, the following information can be derived about surgical masks:

  • Filtration efficiency in experiments implying real people or human manikins is lower than that measured using devices for testing masks.

  • A surgical mask contains the dispersion of respiratory drops of more than 10 µm in diameter according to standards. That said, it is much less effective in stopping the transmission of aerosols of less than 3 µm in diameter.

  • For a perfectly fitted surgical mask, the overall filtration efficiency during exhalation is around 50% for 1–8 µm droplets25 or between 50 and 75% for droplets smaller than 2 µm43. Still, for 1–5 µm droplets, leakage is limited to 0.1 to 0.2%24.

  • A surgical mask primarily protects those around the person wearing it. The wearer is also protected from projections of drops without it being known in which proportions exactly. The protection provided to the wearer during inhalation is not standardised. Experimental studies show that 20–100% of 1–3 µm particles pass through the mask39,40,41,42,44.

  • In practice, leakage is significant, and the mask allows large quantities of air and large numbers of particles to pass around it. While these leaks are not precisely quantified, their location is relatively well known. We can retain the following results:

  • During a cough, 56% of 0.1–7 µm droplets are blocked, while the others escape via side leaks28;

  • During a cough, the fractions of droplets blocked by the mask, passing through it and escaping through the leaks have been evaluated, and the velocity through the leaks is 0.2–0.4 m.s−138;

  • In respiratory events, leaks around the edge of the mask are distributed on average as follows: 35 to 50% around the nose, 20 to 25% on each side of the cheeks, and 6 to 12% along the chin35;

  • In respiratory events, the outward and inward filtration efficiencies of a surgical mask are between 25 and 75% for droplets of less than 5 µm in diameter, and they are of the same order for particles larger than 5 µm43.

  • Apart from its filtration properties, a surgical mask can greatly reduce the velocity of the breath of air emitted during the respiratory cycle30,31,32.

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a vet using a stethoscope on a dog in a clinic

Dogs who contract severe cases of respiratory disease may require extensive treatment, as these cases can impact dogs’ long-term health.

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Dog owners are likely familiar with the respiratory disease commonly known as kennel cough; while most cases have been historically mild, a more severe form of the infection is on the rise.

Because kennel cough is an infectious respiratory disease complex that easily spreads among dogs, Dr. Kathleen Aicher, an assistant professor at the Texas A&M School of Veterinary Medicine and Biomedical Sciences, said it’s important to know the signs and symptoms of the disease as well as what to do if you suspect your dog has been exposed.

“There are a variety of agents that can cause kennel cough, whether bacterial or viral,” Aicher said. “But, sometimes, kennel cough cases can be worsened by other contagious respiratory infections that dogs can get that they are not protected against, or they can become more severely affected, leading to severe kennel cough cases.”

Mild vs. Severe Cases

Traditionally, dogs with a mild case of kennel cough can recover quickly after being prescribed cough suppressants or supportive care that focuses on relieving symptoms, which can include fever, coughing, nasal snuffling or discharge, discharge from the eyes, and sneezing.

On the other hand, dogs who contract severe cases of respiratory disease may require extensive treatment, as these cases can impact dogs’ long-term health. Aicher pointed out that in recent years, veterinarians have observed outbreaks in regions of the country in which younger dogs have been more severely affected.

These dogs have required more diagnostics and supportive care than has historically been the case for “garden variety” kennel cough. Some dogs have developed long-lasting symptoms, which can affect their health for the remainder of their lives.

“Dogs who have a more severe form become affected very quickly and may require hospitalization and oxygen, which are things that dogs with kennel cough don’t usually need,” Aicher said. “Some may have lasting disease or damage in their lungs that persists, leading to the need for longer-term medical therapy or, in rare cases, surgery to remove a diseased portion of the lungs. So it’s important that if owners suspect their dog might have kennel cough that they consult with their veterinarian, regardless of the severity of their symptoms, so that they can know what action to take.”


To best protect against contagious respiratory disease, Aicher said owners should ensure that their dogs are vaccinated against bacteria and viruses that can cause kennel cough, such as the bacteria Bordetella and canine influenza.

“In addition to vaccinating dogs, owners should make sure to bring dogs to places that only accept healthy, vaccinated dogs, and if they know their dog is sick or if their dog is exhibiting symptoms of respiratory illness, owners should not bring them around other dogs,” Aicher said. “This will prevent dogs from unknowingly spreading the illness to other dogs, in case they are contagious.”

When To Go To The Vet

If your dog has been around other dogs, such as at a boarding facility or doggy daycare, owners should take heed of any initial symptoms of respiratory diseases your dog may exhibit following their exposure to other dogs.

“If dogs develop a cough, have trouble breathing, or feel poorly after being around other dogs, then their owners should have them seen by a veterinarian as soon as possible or visit an emergency clinic if their veterinarian is not available,” Aicher said.

Before arriving at the clinic or hospital, Aicher strongly recommends that owners inform the veterinary team who will be providing their dog’s care that the incoming patient has been around other dogs, since kennel cough is contagious.

“The veterinary team may choose to wear personal protective equipment (PPE) or bring your dog through a different entrance into the hospital to prevent the disease from spreading easily. They may take additional precautions that would be different if it was for another cause of respiratory symptoms, like heart disease or asthma,” Aicher said.

While contagious respiratory diseases can have devastating effects, Aicher reiterates to owners that their dogs are very likely to recover fully, especially with the guidance of their veterinarian.

“The majority of dogs recover from this disease without any sort of problems, and they go back to living healthy normal lives,” Aicher said. “For those who are more severely affected, talking to a veterinarian sooner and getting their dog checked out are ways that can help with a faster recovery.”

Respiratory diseases can be troubling for dog owners and their furry friends alike. By prioritizing your dog’s respiratory health and remaining vigilant when your dog begins feeling unwell, owners can relax knowing that their pet is protected while also protecting other dogs.

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