Bronchiectasis-Revisited Essays - Respiratory System, Medicine

Bronchiectasis-Revisited Essays - Respiratory System, Medicine Bronchiectasis-Revisited K. Neelakantan Viswanathan Introduction: Bronchiectasis is a common chronic lung disease characterized by a "vicious cycle" of infection, inflammation and irreversible destruction in the airway (4). Laennec in 1819 defined bronchiectasis based on the findings in an infant who died of whooping cough."Bronemon" in Greek means the windpipe and "ektasis" means stretched out or extension (9).Bronchiectasis is a pathological, irreversible dilatation of the proximal, medium sized and terminal airways more than 2 mm in size, the 4th to the 10th generations being involved (10). Pathology: The normal bronchial wall consisting of cartilage, muscle and elastic tissue gets destroyed and is replaced by fibrous tissue. There is chronic,recurrent infection of secretions that pool within the airways. The organisms produce pigments, proteases and other toxins impairing mucociliary clearance. Epithelial injury is induced by the host inflammatory response, largely due to neutrophil-released mediators and protection against infection is compromised. There is also bronchial and peribronchial inflammation and fibrosis, bronchial wall ulceration, squamous metaplasia and mucous gland hyperplasia. The pulmonary parenchyma supplied by. The abnormal airways contain areas of fibrosis,emphysema,bronchopneumonia and atelectasis in varying combinations (1). The bronchiectatic cavities may be lined by granulation tissue,squamous epithelium or normal ciliated epithelium(6).Bronchiectasis may be accompanied by massive collapse in which all the airways and alveoli distal to the site of collapse are deflated resulting in an airless lobe (13).Reid's Classification (1950) divides this entity into saccular (cystic), fusiform (cylindrical) and varicose types (7). In addition there are follicular, nodular and traction types. There is transmural inflammation and mucosal oedema in cylindrical types, cratering and ulceration in cystic types with bronchial arteriole neo-vascularisation and distortion due to scarring or obstruction from repeated infections in the varicose types (4). In traction types there is extensive volume loss of lung bringing the upper and lower parts of the spine together with concavity to the affected side. Bronchiectasis commonly affects lower lobes, the left more frequently than the right. Next in frequency are the right middle lobe and the lingual (8). The apical segment is spared (12).Aspiration commonly affects the right lung and the lower lobes or the posterior segment of the upper lobes (4).Bronchiectasis sicca involves the upper lobes and is characterized by haemoptysis instead of sputum production, the aetiology, most often, being tuberculosis. Cystic fibrosis and allergic bronchopulmonary aspergillosis (ABPA) also affect the upper lobes.ABPA produces proximal or central (perihilar) bronchiectasis involving 4th-7th generations. Nodular bronchiectasis occurs in Mycobacterium avium infections. It is common in white women aged 55 and above with chronic cough with middle lobe or lingular involvement (4). Pseudo bronchiectasis occurs in expansion of a collapsed lung, usually after pneumonia. Aetiology: The causes of bronchiectasis may be easily remembered as follows: Bordetella pertussis infections Respiratory syncitial virus, Rheumatoid arthritis,Riley -Day syndrome,Relapsing polychondritis Obstruction by foreign body Neoplastic / Nodal compression Chagas disease Hypogammaglobulinaemia (especially selective deficiency of IgG2), HIV infection,Herpes simplex,Histoplasmosis Influenza,Inflammatory bowel diseases,Interstitial lung disease (fibrosing alveolitis) Exanthems-measles, mumps Cystic fibrosis, Congenital sequestrated lung. Coeliac disease, Ciliary dyskinesia (primary), in which the respiratory mucosal biopsy shows broken or missing ciliary spokes Tuberculosis,Toxins- ammonia, paraquat Aspiration of gastric contents,Alcoholism,Adenovirus infections,Alpha-1- antitrypsin deficiency,Atypical Mycobacteria (avium),Atypical pneumonia( Mycoplasma), Allergic bronchopulmonary aspergillosis (ABPA) Systemic complement deficiencies, Sjogren's syndrome,Sarcoidosis Idiopathic (commonest) Syndromes associated with bronchiectasis Kartagener's syndrome: an autosomal recessive' disorder, described in 1933 by a pediatrician, characterized by situs inversus, frontal sinusitis or agenesis of frontal sinuses and bronchiectasis. It is also associated with immotile cilia, due to an abnormal protein involved in the modified ciliary motility causing absence or aberrance of dynein arms, and hence persons with Kartagener's syndrome are infertile. The situs inversus is the chance result of embryonic migration of viscera rather than the normal cilia- dependent placement of internal organs (12). . Young's syndrome: characterized by obstructive azoospermia as a result of enlarged, palpable and obstructed epididymal head and obstruction by inspissated secretions (2). Williams Campbell syndrome: characterized by expiratory collapse of proximal airways on bronchoscopy. There is generalized bronchial cartilage deficiency leading to bronchomalacia. Mounier-Kuhn syndrome: characterised by congenital deficiency of bronchial cartilage associated with tracheobronchomegaly. Enlargement of the airways and deep corrugations produced by the redundant musculo-membranous tissues between the cartilaginous rings gives roentgenographic appearance of multiple diverticulae on CT (lO). Brock's syndrome: characterized by right middle lobe collapse, the bronchiectasis being caused by a foreign body or enlarged lymph node, usually tuberculous. Chandra- Khetarpal syndrome:characterized by levocardia, bronchiectasis and frontal sinusitis. Ciliary dysfunction is not a feature of this syndrome (3). MacLeod's (Swyer-James)syndrome: in which the disease is associated with a unilateral hyperluscent lung and characterized by brochiolitis obliterans (4). Yellow nail syndrome: associated with lymphedema and pleural effusion due to hypoplastic lymphatics. Childhood pentad of bronchiectasis:Whooping cough, measles, mumps, influenza, and primary complex are considered to be childhood infections that predispose to bronchiectasis in adult life. Clinical Features: Persons with bronchiectasis bring out copious foul smelling khaki-coloured sputum

The French Revolution, Its Outcome, and Legacy

The French Revolution, Its Outcome, and Legacy The outcome of the French Revolution, which began in 1789 and lasted for more than a decade, had numerous social, economic, and political effects not just in France but also in Europe and beyond.   Prelude to Revolt By the late 1780s, the French monarchy was on the brink of collapse. Its involvement in the American Revolution had left the regime of King Louis XVI bankrupt and desperate to raise funds by taxing the wealthy and the clergy. Years of bad harvests and rising prices for basic commodities led to social unrest among the rural and urban poor. Meanwhile, the growing middle class (known as the bourgeoisie) was chafing under an absolute monarchical rule and demanding political inclusion. In 1789  the king called for a meeting of the Estates-General- an advisory body of clergy, nobles, and bourgeoisie that had not convened in more than 170 years- to garner support for his financial reforms. When the representatives assembled in May of that year, they couldnt agree on how to apportion representation. After two months of bitter debate, the king ordered delegates locked out of the meeting hall. In response, they convened on June 20 on the royal tennis courts, where the bourgeoisie, with the support of many clergy and nobles, declared themselves the new governing body of the nation, the National Assembly, and  vowed to write a new constitution. Although Louis XVI agreed  in principle to these demands, he began plotting to undermine the Estates-General, stationing troops throughout the country. This alarmed the peasants and middle class alike, and on July 14, 1789, a mob attacked and occupied the Bastille prison in protest, touching off a wave of violent demonstrations nationwide. On Aug. 26, 1789, the National Assembly  approved the Declaration of the Rights of Man and of the Citizen. Like the Declaration of Independence in the United States, the French declaration guaranteed all citizens equal, enshrined property rights and free assembly, abolished the absolute power of the monarchy and established representative government. Not surprisingly, Louis XVI refused to accept the document, triggering another massive public outcry. The Reign of Terror For two years, Louis XVI and the National Assembly co-existed uneasily as reformers, radicals, and monarchists all jockeyed for political dominance. In April 1792 the Assembly declared war on Austria. But it quickly went badly for France, as Austrian ally Prussia joined in the conflict; troops from both nations soon occupied French soil. On Aug. 10, French radicals took the royal family prisoner at Tuileries Palace. Weeks later, on Sept. 21, the National Assembly abolished the monarchy entirely and declared France a republic. King Louis and Queen Marie-Antoinette were tried hastily and found guilty of treason. Both would be beheaded in 1793, Louis on Jan. 21 and Marie-Antoinette on Oct. 16. As the Austro-Prussian war dragged on, the French government and society, in general, were mired in turmoil. In the National Assembly, a radical group of politicians seized control and began implementing reforms, including a new national calendar and the abolition of religion. Beginning in September 1793, thousands of French citizens, many from the middle and upper classes, were arrested, tried, and executed during a wave of violent repression aimed at the Jacobins opponents, called the Reign of Terror.   The Reign of Terror would last until the following July when its Jacobin leaders were overthrown and executed. In its wake, former members of the National Assembly who had survived the oppression emerged and seized power, creating a conservative backlash to the ongoing French Revolution. Rise of Napoleon On Aug. 22, 1795, the National Assembly approved a new constitution that established a representative system of government with a bicameral legislature similar to that in the U.S. For the next four years, the French government would be beset by political corruption, domestic unrest, a weak economy, and ongoing efforts by radicals and monarchists to seize power. Into the vacuum strode French Gen. Napoleon Bonaparte. On Nov. 9, 1799, Bonaparte backed by the army overthrew the National Assembly and declared the French Revolution over. Over the next decade and a half, he could consolidate power domestically as he led France in a series of military victories across much of Europe, declaring himself emperor of France in 1804. During his reign, Bonaparte continued the liberalization that had begun during the Revolution, reforming its civil code, establishing the first national bank, expanding public education, and investing heavily in infrastructures like roads and sewers. As the French army conquered foreign lands, he brought these reforms, known as the Napoleonic Code, with him, liberalizing property rights, ending the practice of segregating Jews in ghettos, and declaring all men equal. But Napoleon would eventually be undermined by his own military ambitions and be defeated in 1815 by the British at the Battle of Waterloo. He would die in exile on the Mediterranean island of St. Helena in 1821. Revolutions Legacy and Lessons With the advantage of hindsight, its easy to see the positive legacies of the French Revolution. It established the precedent of representational, democratic government, now the model of governance in much of the world. It also established liberal social tenets of equality among all citizens, basic property rights, and separation of church and state, much as did the American Revolution.   Napoleons conquest of Europe spread these ideas throughout the continent, while further destabilizing the influence of the Holy Roman Empire, which would eventually collapse in 1806. It also sowed the seeds for later revolts in 1830 and 1849 across Europe, loosening or ending the monarchical rule that would lead to the creation of modern-day Germany and Italy later in the century, as well as sow the seeds for the Franco-Prussian war and, later, World War I. Sources Editors of the Encyclopaedia Brittanica. French Revolution. 7 February 2018.History.com staff. French Revolution. History.com.The Open University staff. French Revolution. Open.edu.Roy Rosenzweig Center for History and New Media staff. Legacies of the Revolution. chnm.gmu.edu.