Correlation Study between COPD and Heart Failure in Elderly Patient

Heart failure and chronic obstructive pulmonary disease (COPD) are acquiring significant morbidity and mortality and the amalgamation presents many diagnostic challenges. Assessment of cardiac and pulmonary function by echocardiography and pulmonary function tests should be executed in all patients with cautious explanation to avoid misdiagnosis and wrong treatment. Both conditions share overlapping pathophysiological processes. Both functional status and quality of life are greatly influenced by these and associated with high morbidity and mortality rates leading to increase the health-care costs. Although both diseases have been studied extensively, information about the correlation between heart failure and COPD is lacking. Classifying the reason of breathing symptoms among people with both the diseases can be demanding. Therefore it is plausible that a considerable proportion of patients with a diagnosis of COPD have associated heart failure, which ruins unrecognized by primary care physicians or pulmonologists. This study's aim was to assess the relationship between chronic obstructive pulmonary disease and heart failure among elderly patients with chronic cough and dyspnea. This study was done in 100 patient's ≥40 years with a GP (general physician) diagnosis of COPD. Descriptive cross sectional study was carried out in the Department of Medicine, Shaheed Ziaur Rahman Medical College Hospital, Bogra, Bangladesh from November 2011 to April 2012. A total of 100 cases of chronic cough with breathlessness coming into out patient department and admitted into Department of Medicine of Shaheed Ziaur Rahman Medical College Hospital, Bogra, Bangladesh were included according to inclusion and exclusion criteria. Informed written consent was taken from the participants and data was collected by a questionnaire and relevant investigations were done. Data were analyzed with SPSS software and were expressed as mean±SE and significance level of differences among the group was calculated by unpaired student's 't' test. In this study among 100 participating patients with a diagnosis of COPD by their physician, in 24(24%) patients had previously unrecognized heart failure. Pearson Correlation study showed that there is significant positive correlation between FEV₁/FVC and Left Ventricular Diastolic Dysfunction and there is also significant positive correlation between FEV₁/FVC and Total Left Ventricular Dysfunction. By this study we recommend that evaluation and assessment of cardiac status is very important in elderly patients with COPD.

Unrecognized Heart Failure in Elderly Patient with COPD

Both of heart failure and chronic obstructive pulmonary diseases are in the elderly. They have an important impact on quality of life and functional status, show high morbidity and mortality rates and lead to extensive health-care costs. Although both diseases have been studied extensively, information about the prevalence of heart failure in stable chronic obstructive pulmonary disease (COPD) patients is lacking. For people who have both the diseases, identifying the cause of breathing symptoms can be challenging. It seems therefore plausible that a considerable proportion of patients with a diagnosis of COPD have concomitant heart failure, which remains unrecognized by primary care physicians or pulmonologists. The main aim of this study was to assess the prevalence of heart failure in patients with a diagnosis of chronic obstructive pulmonary disease. The prevalence of previously unknown heart failure was assessed in 100 patients ≥40 years with a GP (General physician) diagnosis of COPD, in a stable phase of their disease. This descriptive cross sectional study was carried out in the Department of Medicine, Shaheed Ziaur Rahman Medical College hospital, Bogra, Bangladesh from November 2011 to April 2012. A total of 100 cases of chronic breathlessness coming into out patient department and admitted into Department of Medicine of Shaheed Ziaur Rahman Medical College Hospital, Bogra were included based on inclusion & exclusion criteria. After taking informed written consent data was collected by a questionnaire and relevant investigations were done. Then collected data was analyzed and were expressed as mean ±SE and statistical significance of difference among the group was calculated by unpaired students 't' test. In this study we founded among 100 participating patients with a diagnosis of COPD by their physician, in 24 (24%) patients had previously unrecognized heart failure. Therefore, by this study we recommend that evaluation and assessment of cardiac status is very important in elderly patients with COPD.

Expression profiling of pancreatic beta cells: glucose regulation of secretory and metabolic pathway genes

Pancreatic beta cells respond to changes in blood glucose by secreting insulin and increasing insulin synthesis. To identify genes used in these responses, we have carried out expression profiling of beta cells exposed to high (25 mM) or low (5.5 mM) glucose by using oligonucleotide microarrays. Functional clustering of genes that averaged a 2.2-fold or greater change revealed large groups of secretory pathway components, enzymes of intermediary metabolism, cell-signaling components, and transcription factors. Many secretory pathway genes were up-regulated in high glucose, including seven members of the endoplasmic reticulum (ER) translocon. In agreement with array analysis, protein levels of translocon components were increased by high glucose. Most dramatically, the alpha subunit of the signal recognition particle receptor was increased over 20-fold. These data indicate that the translocon and ribosome docking are major regulatory targets of glucose in the beta cell. Analysis of genes encoding enzymes of intermediary metabolism indicated that low glucose brought about greater utilization of amino acids as an energy source. This conclusion was supported by observations of increased urea production under low-glucose conditions. The above results demonstrate genome-wide integration of beta-cell functions at the level of transcript abundance and validate the efficacy of expression profiling in identifying genes involved in the beta-cell glucose response.

Rate of 24-hour blood pressure decline and mortality after spontaneous intracerebral hemorrhage: a retrospective analysis with a random effects regression model

OBJECTIVE

To study the effect of decline in blood pressure on mortality in patients with spontaneous intracerebral hemorrhage (ICH).

DESIGN

Retrospective chart review.

SETTING

University-affiliated teaching hospital.

PATIENTS

Consecutive patients admitted with spontaneous ICH over a 3-year period.

MEASURES

Blood pressure recordings were obtained from the first 24 hrs. Patients (n = 105) with more than five blood pressure recordings and on average greater than one measurement per 2 hrs were included (mean measurements per patient = 20.3). Mean arterial pressure (MAP) recordings over the first 24 hrs after presentation were regressed on time for each patient. Each patient's MAP was calculated as a slope (change mm Hg/hr). We performed logistic regression analyses to determine the effect of MAP slope on mortality and functional outcome, adjusting for other predictive factors including Glasgow Coma Scale (GCS) score and hematoma volume. The effect of MAP slope on mortality was also evaluated in subsets of patients based on age, gender, initial GCS score, initial MAP, treatment status, hematoma volume, and presence of ventricular blood.

MAIN RESULTS

Mean slope of change in MAP was -2.0 mm Hg/hr (+/- 1.9, range -8.5 to +0.6). The slope of MAP (faster rate of decline) within the first 24 hrs was significantly associated with higher mortality (p =.04), independent of initial GCS score and hematoma volume. In subgroup analyses, MAP slope was significantly associated with mortality in men (p = .08), patients with hematoma volume <50 mm3 (p =.08), initial MAP < or = 146 mm Hg (p = .006), and those with initial GCS score > or = 10 (p= .07). MAP slope did not predict functional outcome among survivors.

CONCLUSIONS

A rapid decline in MAP within 24 hrs after presentation is independently associated with increased mortality in patients with ICH. A large, prospective, randomized trial is required to confirm these findings.

Plasma exchange versus intravenous immunoglobulin treatment in myasthenic crisis

We performed a retrospective multicenter chart review to compare the efficacy and tolerance of plasma exchange (PE) and intravenous immunoglobulin (i.v.Ig) in treatment of 54 episodes of myasthenic crisis. After adjustment for other variables, PE (compared with i.v.Ig) was associated with a superior ventilatory status at 2 weeks (partial F = 6.2, p = 0.02) and 1 month functional outcome (partial F = 4.5, p = 0.04). However, the complication rate was higher with PE compared with i.v.Ig (13 versus 5 episodes, p = 0.07).

Human immunodeficiency virus infection and stroke in young patients

OBJECTIVE

To determine the association between human immunodeficiency virus (HIV) infection and stroke among young persons.

DESIGN

Retrospective case-control study.

SETTING

Large, inner-city public hospital.

PARTICIPANTS

All patients aged 19 to 44 years with a diagnosis of stroke, whose HIV status was determined, admitted from January 1990 through June 1994. Controls matched for age and sex were selected from patients who were admitted during the same period for status asthmaticus whose HIV status was known.

MAIN OUTCOME MEASURE

The associations of HIV infection with all strokes and with cerebral infarction, after adjustment for other cerebrovascular risk factors, were evaluated by Mantel-Haenszel stratified analyses. The subtypes and causes of stroke in HIV-infected patients were compared with HIV-seronegative patients.

RESULTS

The HIV infection was associated with stroke (odds ratio [OR], 2.3; 95% confidence interval [CI], 1.0-5.3) and cerebral infarction (OR, 3.4; 95% CI, 1.1-8.9), after adjustment for other cerebrovascular risk factors. Among patients with stroke, cerebral infarction was more frequent in HIV-infected patients than in HIV-seronegative patients (20 [80%] of 25 vs 48 [56%] of 88, P = .04). The frequency of cerebral infarctions associated with meningitis (P < .001) and protein S deficiency (P = .06) was higher in HIV-infected patients than in seronegative patients.

CONCLUSIONS

Our study suggests that HIV infection is associated with an increased risk of stroke, particularly cerebral infarction in young patients. This risk is probably mediated by increased susceptibility of HIV-infected patients to meningitis and protein S deficiency.

Crack cocaine use and stroke in young patients

BACKGROUND AND PURPOSE

Numerous case series have proposed a relationship between "crack" cocaine use and stroke. We performed a retrospective case control study at a large inner-city public hospital to determine the relationship between crack use and stroke among young persons.

METHODS

We reviewed records of all patients aged 20 to 39 years with a diagnosis of stroke, and of controls selected from patients with noncocaine-related diagnoses, admitted from January 1990 through June 1994. We collected information regarding cocaine use, time of last use, route of use, and the results of urine toxicologic studies. We performed backward stepwise logistic regression analyses to determine the association of crack use at any time and acute crack use (defined as use within 48 hours prior to presentation) with stroke and stroke subtypes.

RESULTS

Among patients with information regarding presence or absence of crack use (66 of 144 stroke patients and 99 of 147 controls), crack use at any time was not associated with stroke (odds ratio [OR] = 0.7, 95% CI 0.4-1.8) or cerebral infarction (OR = 0.5, 95% CI 0.2-1.2). Among patients providing temporal information regarding crack use, acute crack use was not associated with stroke (OR = 1.9, 95% CI 0.7-5.1) or cerebral infarction (OR = 1.2, 95% CI 0.4-3.8).

CONCLUSIONS

Crack use at any time or acute crack use was not significantly associated with stroke or cerebral infarction in our patient population.

Controlled study of Escherichia coli diarrheal infections in Bangladeshi children

Diarrheal diseases are highly prevalent in Bangladesh. However, the relative contribution of diarrheagenic Escherichia coli organisms--those that are enterotoxigenic (ETEC), enteropathogenic (EPEC), enteroinvasive, enterohemorrhagic, enteroaggregative, and diffuse adherent--to diarrhea in Bangladeshi populations is not known. With DNA probes specific for these diarrheagenic E. coli strains, we analyzed fecal E. coli from 451 children up to 5 years of age with acute diarrhea seeking treatment at a Dhaka hospital and from 602 matched control children without diarrhea from July 1991 to May 1992. Enteroinvasive E. coli was not isolated from any children; enterohemorrhagic E. coli was not isolated from any diarrheal children but was isolated from five control children; enteroaggregative and diffuse adherent E. coli strains were isolated with similar frequencies from children with and without diarrhea, thereby showing no association with diarrhea; ETEC was significantly associated with diarrhea in the diarrheal children as a whole and especially in the age groups of 0 to 24 months and 37 to 48 months (further analysis suggests an association with diarrhea for the heat-stable toxin only and for both heat-labile- and heat-stable-toxin-producing ETEC only); and EPEC was significantly associated with diarrhea in the diarrhea group as a whole and particularly in infants up to 1 year of age. Further analysis suggested that EPEC strains of only the traditional serogroups were significantly associated with diarrhea. ETEC and EPEC infections peaked during warm months. Our data thus suggest that EPEC and ETEC are important causes of acute diarrhea in children in this setting.

Isolation of enterotoxigenic Bacteroides fragilis from Bangladeshi children with diarrhea: a controlled study

We undertook a controlled study of children younger than 5 years in Bangladesh to determine whether enterotoxigenic Bacteroides fragilis (ETBF) was associated with diarrhea in this population. ETBF was isolated from 22 (6.1%) of 358 patients and 5 (1.2%) of 425 controls (P = 0.0001). In children younger than 1 year, however, low isolation rates (2 to 3%) were found in both patients and controls. In children older than 1 year, the rates were significantly higher in children with diarrhea (16 [9%] of 177) than in controls (2 [1%] of 264; P = 0.00001). When children with mixed infections with other known diarrheal pathogens were removed, the differences in children older than 1 year were still significant (7 [4%] of 177 versus 2 [1%] of 264; P = 0.033). The syndrome associated with ETBF was secretory in nature, with watery diarrhea, and of mild severity. These epidemiological and clinical findings are similar to those from a previous study of White Mountain Apaches in the United States and are the first to suggest that ETBF may also be an important diarrheal pathogen in other geographic areas and in the developing world where diarrhea is highly endemic.

Persistent diarrhoea: efficacy of a rice-based diet and role of nutritional status in recovery and nutrient absorption

A diet based on rice powder, soya-bean oil, glucose, egg-white and salts was given to twenty-six patients of different nutritional status aged 4-18 months with persistent diarrhoea and twenty-five age-matched controls without diarrhoea. Clinical response was monitored during 1 week of dietary treatment and absorption of macronutrients was estimated during a 72 h balance study. Twenty-one patients (81%) recovered from diarrhoea within 7 d. There were significant relationships between nutritional indices, recovery, and absorption of total energy, fat and N. The absorption of fat, protein and carbohydrate in the better nourished controls without diarrhoea was significantly higher than in patients with persistent diarrhoea with better nutrition or malnutrition. The duration of diarrhoea was significantly longer in lighter patients (weight-for-age < 65% NCHS (1976) standard), in wasted patients (weight/height < 80% of NCHS) and those with mid upper arm circumference (MUAC) less than 110 mm. There were negative relationships between the period of recovery and the coefficient of absorption of fat (P < 0.001), total energy intake (P < 0.01) and MUAC (P < 0.05). Weight-for-age and MUAC showed most effective discriminative power for absorption of nutrients. However, the coefficients of absorption for carbohydrate were not different for any pair of nutritional groups. Absorption of all nutrients was also correlated negatively with severity of persistent diarrhoea on admission. The results of the present study indicate that a rice-based diet is highly effective in the management of persistent diarrhoea and less malnutrition aggravates nutrient malabsorption, increases duration and severity of diarrhoea and less severely malnourished patients do not absorb nutrients as well as healthy controls. Malnutrition and the initial severity of diarrhoea are significant determinants of clinical prognosis and nutrient absorption in persistent diarrhoea.

Persistent diarrhoea: management in algorithmic approach using a low-cost rice-based diet in severely malnourished Bangladeshi children

Easy and successful dietary management of persistent diarrhoea has been a long desired goal. Finding an efficient diet which is economically feasible, and easy to prepare in poor homes of developing countries, has not been easy. A dietary algorithm was followed to test the clinical efficacy of an inexpensive and easy to prepare diet made up with rice powder, egg white, glucose, and soya oil. We studied a cohort of 100 severely malnourished children aged between 3 and 36 months with persistent diarrhoea in Dhaka Shisu (children's) Hospital, Bangladesh, during 1990. Initially on a milk-based diet, 26 children (26 per cent) improved while on a subsequent rice-based diet; 65 (88 per cent) of the remaining 74 children improved within a week, with a mean recovery period of 4 days. Patients who did not improve with the rice-based diet were weaned earlier than those who improved. Nine patients failed to improve on the rice-based diet. They were given a soya formula, and only two improved. The remaining seven patients finally improved when a comminuted chicken diet was given. Eight patients died in the hospital with secondary infections of septicaemia and bronchopneumonia. This study offers a simple and effective algorithm on the management of persistent diarrhoea and also demonstrates the success of a rice-based diet, showing promising and feasible means of management of persistent diarrhoea in patients with severe malnutrition.

Maternal nutritional status as a determinant of child health

To determine the relationship between the nutritional status of the mother and that of the child, 339 children aged 3-36 months and their mothers in two urban hospitals and a community out-patient clinic, were studied. The weight and height of both children and their mothers were measured, and body mass indices (BMI) of the mothers were calculated. Socio-economic status, maternal educational level, and dietary information were recorded in a predesigned questionnaire. The child's nutritional status, as indicated by weight for age (as a percentage of NCHS median), was associated with the body mass index of the mother (P < 0.001), socio-economic status of the family (P < 0.001), and breastfeeding status of the child (P < 0.005) in a multivariate analysis after adjusting for several prognostic factors. The results indicate that maternal nutritional status is a proximate determinant of a child's nutritional status and should be considered in programmes aiming at improving child health.

Does antibody to mycobacterial antigens, including lipoarabinomannan, limit dissemination in childhood tuberculosis?

Serum immunoglobulin (Ig) G responses to a variety of mycobacterial antigens were measured in children from the UK, in children with tuberculosis from Hyderabad, India and Dhaka, Bangladesh, classified according to whether the disease was disseminated or localized, and in non-tuberculous controls. Anti-lipoarabinomannan (LAM) IgG responses in UK children showed a marked trough between 6 months and 3 years coincident with the reported peak incidence of disseminated tuberculosis. Geometric mean IgG responses to sonicates of slow-growing mycobacteria (rich in LAM) in 36 children with disseminated tuberculosis were markedly lower than in 99 children with localized tuberculous lesions (for Mycobacterium scrofulaceum P < 0.01, for M. tuberculosis P < 0.01, and for M. vaccae P < 0.01). Responses to purified LAM were also lower in the disseminated tuberculosis group (P < 0.05) but there was no difference between the groups in their response to mycobacterial 65 kDa protein. Multiple regression analysis showed that the reduced response to sonicated mycobacterial antigens and to LAM in children with disseminated disease was independent of age, nutritional status, skin test reactivity, duration of previous symptoms, and city of origin. There was no evidence for sequestration of antibody to immune complexes. These findings are compatible with the hypothesis that children with low levels of antibody to sonicated mycobacterial antigen and to LAM, or those who cannot mount an antibody response, are predisposed to dissemination. A role for antibody in preventing disseminated forms of tuberculosis in childhood has implications for the development of improved vaccines and for the optimum timing of vaccination with bacille Calmette-Guérin.

Persistent diarrhoea: factors affecting absorption and clinical prognosis during management with a rice-based diet

Twenty-six persistent diarrhoea patients aged 4 to 18 months were treated with a diet prepared with rice powder, soya oil, glucose, egg white and water. Absorption of macronutrients was estimated in a 72 h balance study and clinical response was examined during one week of dietary treatment. Nutrient absorption was compared with that of 25 healthy age-matched controls treated with the same diet. Twenty-one patients (81%) recovered from diarrhoea within seven days. Absorption of nutrients was significantly reduced among the persistent diarrhoea patients. More malnourished patients had a significantly reduced absorption of nutrients except carbohydrate and an increased severity and longer duration of diarrhoea. Total gut transit time had significant association with nutrient absorption in the persistent diarrhoea patients. The period of recovery negatively correlated with coefficient of absorption and positively with initial stool weight. Failure to recover was associated with severity of diarrhoea and systemic infection. The study indicates that nutrient absorption is significantly reduced in patients with persistent diarrhoea and nutritional status, and that initial purging rate and intestinal hurry are significantly related to the prognosis and nutrient absorption.

Persistent diarrhea: total gut transit time and its relationship with nutrient absorption and clinical response

The study was undertaken to better understand the role of total gut transit time (TGTT) on the absorption of nutrients in patients with persistent diarrhea. Twenty-six boys aged 3-18 months with persistent diarrhea and 25 age-matched healthy controls were studied. Their TGTT was measured with charcoal markers during their treatment with a diet made up with rice powder soya oil, glucose, and egg white. Coefficients of absorption of nutrients were estimated in a 72-h balance study. The median TGTTs in patients and controls were 5 and 11.6 h, respectively. Among the patients, the TGT correlated significantly with absorption of total energy (p less than 0.01), absorption of fat (p less than 0.01), stool frequency (p less than 0.01), and stool weight during the 1st 24 h (p less than 0.01). Coefficients of absorption of energy, fat, and carbohydrate were significantly different among the patients above or below the median transit time (5 h). None of these relationships was present among the healthy controls. The TGTT was negatively associated with the duration of clinical recovery. The results of this study suggested that intestinal transit time is an important factor for absorption of nutrients that may influence clinical recovery in patients with persistent diarrhea.

A randomised, double-blind clinical trial of a maltodextrin containing oral rehydration solution in acute infantile diarrhoea

We compared the efficacy of a maltodextrin containing oral rehydration salts (ORS) solution with that of the WHO recommended glucose-ORS solution in a double blind randomized study of treating 69 children (33 in experimental group; 36 in control group) aged 4-36 months with acute diarrhoea causing mild to moderate dehydration. Both the groups of children were similar in initial clinical characteristics and received only ORS solutions. No significant differences in stool output (median 88.0, range 34-320 g/kg body wt. in experiment vs 75.0, 25-410 g/kg in control), intake of ORS solution (125.0, 58-360 ml/kg body wt. vs 154, 130-250 ml/kg), and duration of recovery from diarrhoea (2.0 d, range 1-6 vs 2.0 d, 1-9) were found between the groups. The haematocrit and serum electrolyte values in the two groups 24 hours after starting treatment were also similar. The results suggest that the ORS containing maltodextrin (50 g/l) in place of glucose has no advantage over WHO-ORS in correcting mild to moderate dehydration of children with acute diarrhoea.

Persistent diarrhoea: clinical efficacy and nutrient absorption with a rice based diet

Twenty six infant boys, aged 4 to 18 months, suffering from persistent diarrhoea and 25 age matched healthy controls without diarrhoea were given a diet based on rice powder, egg white, glucose, and soya oil. The clinical efficacy of the diet was studied and a 72 hour metabolic balance study was done. Twenty one patients recovered from diarrhoea within seven days. Median coefficients of absorption of nutrients in persistent diarrhoea patients were 68.0% (range 28.0 to 92.0) for total energy, 60.0% (range 21.0 to 97.0) for fat, 53.0% (range -122.0 to 82.0) for nitrogen, and 81.0% (range 23.0 to 97.0) for carbohydrates. The corresponding values among the control subjects were 90.0% (range 76.0 to 99.0), 95.0% (range 71.0 to 99.0), 70.0% (range 10.0 to 95.0), and 93.0% (range 85.0 to 98.0) respectively. Absorption of all macronutrients in the control subjects was on average significantly higher than in the patients. Nutrient absorption is substantially reduced in persistent diarrhoea and a rice based diet is clinically effective in most patients.