Pilot study of factors associated with exacerbations in chronic bronchitis

The factors associated with exacerbations of chronic bronchitis were investigated in a pilot study of 23 male patients over a period of 29 months. There were 63 exacerbations—56 were fully investigated and in seven only serological studies were possible. Evidence of the presence of an infective agent was sought in the early stages of the exacerbations and during relative quiescence. Significantly more potential pathogens, both bacterial (pneumococci and Haemophilus influenzae) and viral and mycoplasmal, were found during exacerbations than in quiescent periods. It was not possible to demonstrate that atmospheric pollution or low temperature influenced exacerbations, but the data are insufficient to exclude a small effect.It is emphasized that the value of future work on these lines would be increased if agreement could be reached on the definition of an exacerbation.     

X-ray diagnosis of neurogenic osteoarthropathies

The paper is concerned with roentgenoanatomical analysis of the osteoarticular system in 607 patients with syringomyelia (21), tabes dorsalis (42), diabetes mellitus (324), psoriasis (187) and traumatic injuries of the spine and spinal marrow (33). In 58 patients tabetic (18), syringomyelitic (12), diabetic (18), psoriatic (9) and traumatic (1) osteoarthropathy was diagnosed. A study of the x-ray picture of osteoarthropathy revealed 2 types of disease: either with the prevalence of osteolytic or proliferative changes. The x-ray picture of osteoarthropathy was presented. The features of tabetic, syringomyelitic, diabetic and psoriatic arthropathies were described.     

Infective Factors in Exacerbations of Bronchitis and Asthma

Infections of the respiratory tract were studied in a group of families each containing a patient with chronic bronchitis or with asthma. A wide variety of infective agents may be associated with exacerbations in susceptible subjects, but the types of organism to which patients are most at risk differ according to the family structure. Exacerbations in the susceptible subject are more likely to be related to viral infections when the family contains children than when it does not.Two patients with asthma experienced frequent respiratory infections, many of which provoked attacks of asthma.     

Endocrine and Metabolic Disorders in Bronchial Carcinoma

In an unselected series of 185 patients with histologically confirmed bronchial carcinoma 16 had endocrine disturbances attributable to the tumour (excluding pulmonary osteoarthropathy). Of these, 11 patients had hypercalcaemia; three inappropriate secretion of antidiuretic hormone; one Cushing''s disease; three hypertrophic osteoarthropathy; and one gynaecomastia. Cushing''s disease and inappropriate antidiuresis are specifically associated with oat-cell tumours, and hypercalcaemia occurs most frequently with squamous carcinoma. A negative correlation exists between gynaecomastia and osteoarthropathy on the one hand and oat-cell carcinoma on the other.     

High-dose corticosteroids in severe acute asthma.

Twenty-six patients admitted to hospital for treatment of severe exacerbations of asthma unresponsive to bronchodilators were assigned to high-, medium-, or low-dose corticosteroid treatment regimens. The rates of recovery were assessed by changes in pulse rate, peak expiratory flow rate, and spirometric measurements and were not related to the dose of corticosteroids given. Very high systemic doses of corticosteroids do not offer significant advantages in treating severe exacerbations of asthma.     

Influences on hospital admission for asthma in south Asian and white adults: qualitative interview study

ObjectiveTo explore reasons for increased risk of hospital admission among south Asian patients with asthma.DesignQualitative interview study using modified critical incident technique and framework analysis.SettingNewham, east London, a deprived area with a large mixed south Asian population.Participants58 south Asian and white adults with asthma (49 admitted to hospital with asthma, 9 not admitted); 17 general practitioners; 5 accident and emergency doctors; 2 out of hours general practitioners; 1 asthma specialist nurse.ResultsSouth Asian and white patients admitted to hospital coped differently with asthma. South Asians described less confidence in controlling their asthma, were unfamiliar with the concept of preventive medication, and often expressed less confidence in their general practitioner. South Asians managed asthma exacerbations with family advocacy, without systematic changes in prophylaxis, and without systemic corticosteroids. Patients describing difficulty accessing primary care during asthma exacerbations were registered with practices with weak strategies for asthma care and were often south Asian. Patients with easy access described care suggesting partnerships with their general practitioner, had better confidence to control asthma, and were registered with practices with well developed asthma strategies that included policies for avoiding hospital admission.ConclusionsThe different ways of coping with asthma exacerbations and accessing care may partly explain the increased risk of hospital admission in south Asian patients. Interventions that increase confidence to control asthma, confidence in the general practitioner, understanding of preventive treatment, and use of systemic corticosteroids in exacerbations may reduce hospital admissions. Development of more sophisticated asthma strategies by practices with better access and partnerships with patients may also achieve this.

What is already known on this topic

South Asian patients with asthma are at increased risk of hospital admission with asthma compared with white patientsNo consistent differences in severity or prevalence of asthma, prescribed drugs, or asthma education have been described, and interventions to reduce admission rates in Asian patients have met with variable success

What this study adds

Compared with white patients, south Asian patients admitted to hospital with asthma had less confidence to control asthma, were unfamiliar with the concept of preventive medication, and had less confidence in their general practitionersSouth Asian patients managed asthma attacks through family advocacy and without systematic changes in prophylaxis and without systemic corticosteroidsPatients reporting difficulty in accessing primary care during attacks were often south Asian     

Elemental diet as primary treatment of acute Crohn's disease: a controlled trial.

Acute exacerbations of Crohn''s disease are usually treated with prednisolone or potentially more toxic immunosuppressive drugs or by surgery. In pilot studies replacing the normal diet by a protein free elemental diet also induced remission. A controlled trial was therefore conducted in which 21 patients acutely ill with exacerbations of Crohn''s disease were randomised to receive either prednisolone 0.75 mg/kg/day or an elemental diet (Vivonex) for four weeks. Assessment at four and 12 weeks showed that the patients treated with the elemental diet had improved as much as and by some criteria more than the steroid treated group. Elemental diet is a safe and effective treatment for acute Crohn''s disease.     

Elemental diets in treatment of acute Crohn's disease.

Twenty-seven patients with 32 acute exacerbations of Crohn''s disease were treated for four weeks with an elemental diet. At the end of treatment 29 of the exacerbations had remitted both clinically and biochemically. After six months six patients had relapsed. These findings suggest that the elemental diet is effective in treating acute Crohn''s disease, but the reasons are not clear. The diet may be effective because it provides nutritional support, is hypoallergenic, acts as a medical bypass from the affected area, or alters bowel flora. The patient''s general wellbeing is improved by the supply of adequate energy and essential foodstuffs in a form easily available without further digestion and given in a safe, simple, non-toxic way.     

核型多角体病毒的增值与棉铃虫血淋巴酯酶的变化

核型多角体病毒（NPV）对同源棉铃虫有很强的毒杀作用,是重要杀虫资源。病毒感染导致宿主代谢紊乱,引起一系列生化反应的变化,可通过一定方法观察到其表征,此为病毒感染的病理生化特征。昆虫血淋巴对于病毒感染引起的全身症状具有重要作用,并影响宿主物质和能量代谢的性质与水平,反映出病毒一宿主的互作关系。本文以血淋巴酯酶同工酶（EST）为感病指标,对其感染变化进行研究。1材料和方法11材料11．呈供试病毒棉铃虫核型多用体病毒．取自湖北仙桃磷肥厂生化分厂。1．1．2供试昆虫棉铃虫三龄幼虫,由该厂提供,半人工饲料饲养。豆…     

马方综合征并发感染性心内膜炎的外科治疗体会

目的：探讨马方综合征并发感染性心内膜炎的外科治疗的体会。方法：回顾性分析2009年7月至2012年12月我院30例马方综合征并发感染性心内膜炎患者,男19例,女11例,年龄23.58（41．6±15．2）岁,所有患者均进行了抗生素治疗和心瓣膜置换或成形术,其中对患者进行经典Bent,all手术12例,纽扣法Bentall手术18例,比较分析手术治疗马方综合征并发感染性心内膜炎疗效。结果：手术时间276．742（405．0±125．0）min,体外循环时间115—319（159．0±43．0）rain,机械通气辅助时间1～12（2．4±2．0）d．住院时间10．60（28．5±11．0）d,术后出现并发症有7例,经二期手术治愈有5例,2例抢救无效死亡,并发症发生率为23.3％,死亡率为6．7％。结论：对于马方综合征并发感染性心内膜炎患者,正确把握手术的时机和抗感染药物治疗剂量,积极采取外科手术治疗是最佳的治疗方法。     

Infectious exacerbations of chronic obstructive pulmonary disease associated with respiratory viruses and non-typeable Haemophilus influenzae

Infectious exacerbations of chronic obstructive pulmonary disease (COPD) have been reported to occur with both viral and bacterial pathogens. In this study, 35 exacerbations associated with the isolation of non-typeable Haemophilus influenzae from sputum were identified as part of a prospective longitudinal study. Samples from these patients were subjected to immunoassays to identify a new immune response to the homologous isolate of non-typeable H. influenzae to more accurately assess a bacterial etiology. These patients also were studied carefully for evidence of viral infection using viral culture, serology and polymerase chain reaction-based assays. Sixteen of 35 exacerbations (45.7%) were associated with evidence of acute viral infection and 11 of the 35 exacerbations (31.4%) were associated with the development of new serum IgG to homologous non-typeable H. influenzae. Overall, evidence of infection with a respiratory virus or non-typeable H. influenzae was seen in 24 of 35 exacerbations (68.6%). No association between viral infection and immune response to non-typeable H. influenzae was observed, although a trend toward an immune response to non-typeable H. influenzae and absence of viral infection was seen. The results show that exacerbations in adults with COPD were associated with infection caused by virus alone, non-typeable H. influenzae alone, or virus and non-typeable H. influenzae simultaneously.     

Atopic manifestations in the acquired immune deficiency syndrome: response to recombinant interferon gamma.

Six patients with the acquired immune deficiency syndrome (AIDS) had exacerbations or recurrences of previously quiescent atopic disease when they developed immunodeficiency. Four developed a different atopic illness from that suffered previously. Atopic symptoms developed within three months after the patients developed AIDS or during prodromal illness. Two of the patients were treated with recombinant interferon gamma: both showed a striking improvement in symptoms and cellular immunity. These results indicate that cellular immunity, through interferon gamma, may have a role in regulating atopic disease.     

Withdrawal of inhaled corticosteroids in individuals with COPD - a systematic review and comment on trial methodology

Inhaled corticosteroids (ICS) reduce COPD exacerbation frequency and slow decline in health related quality of life but have little effect on lung function, do not reduce mortality, and increase the risk of pneumonia. We systematically reviewed trials in which ICS have been withdrawn from patients with COPD, with the aim of determining the effect of withdrawal, understanding the differing results between trials, and making recommendations for improving methodology in future trials where medication is withdrawn. Trials were identified by two independent reviewers using MEDLINE, EMBASE and CINAHL, citations of identified studies were checked, and experts contacted to identify further studies. Data extraction was completed independently by two reviewers. The methodological quality of each trial was determined by assessing possible sources of systematic bias as recommended by the Cochrane collaboration. We included four trials; the quality of three was adequate. In all trials, outcomes were generally worse for patients who had had ICS withdrawn, but differences between outcomes for these patients and patients who continued with medication were mostly small and not statistically significant. Due to data paucity we performed only one meta-analysis; this indicated that patients who had had medication withdrawn were 1.11 (95% CI 0.84 to 1.46) times more likely to have an exacerbation in the following year, but the definition of exacerbations was not consistent between the three trials, and the impact of withdrawal was smaller in recent trials which were also trials conducted under conditions that reflected routine practice. There is no evidence from this review that withdrawing ICS in routine practice results in important deterioration in patient outcomes. Furthermore, the extent of increase in exacerbations depends on the way exacerbations are defined and managed and may depend on the use of other medication. In trials where medication is withdrawn, investigators should report other medication use, definitions of exacerbations and management of patients clearly. Intention to treat analyses should be used and interpreted appropriately.     

Propionibacterium acnes in the etiology of endocarditis]

Propionibacterium acnes is the gram positive anaerobic bacteria belongs to the normal skin and oral microbial flora. The participation of this microorganism in the infective endocarditis is still controversial. The aim of the study was to perform the diagnostic and therapeutic difficulties in 5 patients with infective endocarditis caused by Propionibacterium acnes. In 3 out of 5 patients the infective endocarditis developed after prosthesis valve replacement, in 2 others on the native valves. The inserted prostheses were mechanical ones, propionibacterium acnes was identified as causative organisms in all of the causes (two positive blood and/or valve culture). The bacterial strains were sensitive to the antibiotics as: penicillins, cephalosporins, clindamycin, and vancomycin, however cephalosporins used at the beginning of the treatment in 3 patients and clindamycin in 1 patient had limited clinical efficacy. Later treatment with timentin, augmentin and tienamycin was successful in 3 patients; one patient was cured with vancomycin. One patient died because of septic, embolic complication in early stage of illness. We conclude the effectiveness of penicillins in combination with clavulanic acid and tienamycin in therapy of infective endocarditis due to Propionibacterium acnes. The treatment should be lasted during 4-6 weeks.     

Assessment of Health Status in Patients with Newly Diagnosed Chronic Obstructive Pulmonary Disease

Subject

Chronic obstructive pulmonary disease (COPD) is a common disease worldwide. This study aimed to investigate the health status of patients with newly diagnosed COPD.

Methods

A total of 45 healthy controls and 218 patients with newly diagnosed COPD were recruited. Pulmonary function test (PFT) values, COPD assessment test (CAT) scores, exacerbation history, and demographics were recorded.

Results

Forced expiratory volume in 1 s percent (FEV1%) predicted was significantly decreased and the CAT score was significantly increased in patients with COPD compared with healthy controls (P <0.001). Among the COPD patients, the most commonly reported respiratory symptoms were cough (86.7%), sputum (80.3%), and dyspnea (45%). A total of 86.2% patients were in the moderate or severe stage (spirometric classification) of COPD, and 71.5% were in Group C or Group D (combined assessment). A total of 33.9% of the patients had 2 or more exacerbations in the previous year. Nearly half of the patients (45.4%) had a high CAT score of ≥10. Patients with a history of more exacerbations had a higher CAT score.

Conclusions

Most COPD patients were symptomatic and appeared to have moderate to severe airflow limitation or a high risk of exacerbation before definitely being diagnosed with COPD using the PFT.     

Viral Antibody Levels and Clinical Status in Acute Exacerbations of Chronic Bronchitis: a Controlled Prospective Study

A controlled prospective study was made of a group of patients with chronic bronchitis, in which serum antibodies against a group of viruses and Mycoplasma pneumoniae were estimated at regular intervals. Sixteen significant rises in antibody titre were shown, of which eight were associated with clinical acute exacerbations of bronchitis. In individual patients no correlation was found between the number of acute exacerbations or the aetiological agent and persistent change in ventilatory function as expressed by the F.E.V._0.75.This study was compared with the results of a previous parallel investigation of the same patients done to study the significance of rhinovirus infections. In the present investigation 12% of the acute exacerbations were associated with the 11 agents tested compared with 14% associated with rhinoviruses in the earlier work.     

Platelet receptor polymorphisms do not influence Staphylococcus aureus-platelet interactions or infective endocarditis

Cardiac vegetations result from bacterium-platelet adherence, activation and aggregation, and are associated with increased morbidity and mortality in infective endocarditis. The GPIIb/IIIa and FcγRIIa platelet receptors play a central role in platelet adhesion, activation and aggregation induced by endocarditis pathogens such as Staphylococcus aureus, but the influence of known polymorphisms of these receptors on the pathogenesis of infective endocarditis is unknown. We determined the GPIIIa platelet antigen Pl(A1/A2) and FcγRIIa H131R genotype of healthy volunteers (n?=?160) and patients with infective endocarditis (n?=?40), and investigated the influence of these polymorphisms on clinical outcome in infective endocarditis and S. aureus-platelet interactions in vitro. Platelet receptor genotype did not correlate with development of infective endocarditis, vegetation characteristics on echocardiogram or the composite clinical end-point of embolism, heart failure, need for surgery or mortality (P?>?0.05 for all), even though patients with the GPIIIa Pl(A1/A1) genotype had increased in vivo platelet activation (P?=?0.001). Furthermore, neither GPIIIa Pl(A1/A2) nor FcγRIIa H131R genotype influenced S. aureus-induced platelet adhesion, activation or aggregation in vitro (P?>?0.05). Taken together, our data suggest that the GPIIIa and FcγRIIa platelet receptor polymorphisms do not influence S. aureus-platelet interactions in vitro or the clinical course of infective endocarditis.     

Endocardiac infectivity and binding to extracellular matrix proteins of oral Abiotrophia species

Microorganisms of the genus Abiotrophia, formerly known as nutritionally variant streptococci, are members of the oral flora and often isolated from patients with endocarditis, but pathogenicity of oral Abiotrophia species has not been examined yet. In this study, 17 strains isolated from healthy human oral cavities and 7 reference strains (all derived from patients with endocarditis) of Abiotrophia spp. were tested for their abilities to cause infections in damaged heart tissues in catheterized rats and to adhere to extracellular matrix proteins in vitro. The reference strains of A. defectiva and A. adiacens showed high infectivities in the rats. Four oral isolates of these two species showed similarly high infectivities and three had moderate infectivities. Most of 10 oral strains of A. para-adiacens and A. elegans were found to be generally less infective. The highly infective A. adiacens strains showed markedly high fibronectin-binding capacity, suggesting a possible relationship between the fibronectin-binding capacity and damaged heart tissue infectivity of the Abiotrophia species. A. defectiva strains which were also highly infective had moderate levels of binding to fibronectin and other extracellular matrix proteins. Most of A. para-adiacens and A. elegans strains showed low or negligible binding capacities to any extracellular matrix proteins tested.     

Bronchodilator treatment in moderate asthma or chronic bronchitis: continuous or on demand? A randomised controlled study.

OBJECTIVE--To examine the effect of bronchodilator treatment given continuously versus on demand on the progression of asthma and chronic bronchitis and to compare the long term effects of a beta 2 adrenergic drug (salbutamol) and an anticholinergic drug (ipratropium bromide). DESIGN--Two year randomised controlled prospective ''crossover'' study in which patients were assigned to one of two parallel treatment groups receiving continuous treatment or treatment on demand. SETTING--29 general practices in the catchment area of the University of Nijmegen. PATIENTS--223 patients aged greater than or equal to 30 with moderate airway obstruction due to asthma or chronic bronchitis, selected by their general practitioners. INTERVENTIONS--1600 micrograms salbutamol or 160 micrograms ipratropium bromide daily (113 patients) or salbutamol or ipratropium bromide only during exacerbations or periods of dyspnoea (110). No other pulmonary treatment was permitted. MAIN OUTCOME MEASURES--Decline in ventilatory function and change in bronchial responsiveness, respiratory symptoms, number of exacerbations, and quality of life. RESULTS--Among 144 patients completing the study, after correction for possible confounding factors the decline in forced expiratory volume in one second was -0.072 l/year in continuously treated patients and -0.020 l/year in those treated on demand (p less than 0.05), irrespective of the drug. The difference in the decline in patients with asthma was comparable with that in patients with chronic bronchitis (asthma: 0.092 v -0.025 l/year; chronic bronchitis: -0.082 v -0.031 l/year). Bronchial responsiveness increased slightly (0.4 doubling dose) with continuous treatment in chronic bronchitis, but exacerbations, symptoms, and quality of life were unchanged. Salbutamol and ipratropium bromide had comparable effects on all variables investigated. CONCLUSIONS--Continuous bronchodilator treatment without anti-inflammatory treatment accelerates decline in ventilatory function. Bronchodilators should be used only on demand, with additional corticosteroid treatment, if necessary.