Metabolic antianginal agent ranolazine offers good symptom relief in a patient with inoperable severe aortic stenosis

Severe inoperable aortic stenosis is a challenge for clinicians. Management of symptoms with traditional antianginal agents, which exert hemodynamic changes often may not be possible in such patient groups. We report the first known case of the safe use of ranolazine with good symptomatic relief of angina in an 88-year-old lady with isolated severe aortic stenosis (without significant coronary disease) who was not suitable for surgical or percutaneous valve replacement due to medical comorbidity.     

GM-CSF in the treatment of a patient with severe methotrexate intoxication

Abstract. This case report describes the successful treatment of severe methotrexate intoxication in a 72-year-old female patient. Following two prior uneventful courses of a polychemotherapy regimen including low-dose intravenous (i.v.) methotrexate, the patient presented with fever, polymucositis, incipient pyodermia, acute renal failure and pancytopenia 9 days after the third application. Severe methotrexate overdose was confirmed by serum levels. Using a polypragmatic treatment approach focusing on renal function and including granulocyte-macrophage-colony-stimulating factor (GM-CSF) this life threatening and nearly fatal intoxication was successfully treated. This case report demonstrates that GM-CSF might contribute to rapid reconstitution of leukopoiesis once methotrexate serum levels are in the subtoxic range.     

The perception of dyspnoea in patients with asthma, before and following treatment with inhaled glucocorticosteroids

This study was designed in order to establish the perception of breathlessness during rest and while breathing against resistance, in patients with asthma, before and after 8 weeks of inhaled glucocorticoids (IGC) treatment and to compare these parameters in patients with and without improvement in FEV1. Sixty-seven asthmatic patients, with moderate asthma, attending the asthma clinic, and 20 normal subjects were studied. After a 2-week run-in period, in which the subjects were asked to use exclusively beta2-agonists as needed, the asthmatic patients were randomized to receive either treatment with IGC, 250 microg of fluticasone propionate (FP) twice a day, via a diskhaler (47 patients), or to receive placebo (20 patients) and to serve as a control group, for 8 weeks. Spirometry and measurements for the sensation of dyspnoea were performed before and at the end of the treatment period. The mean dyspnoea score during breathing against resistance was significantly lower (P<0.05) in the patients with asthma than in normal subjects, before entering the study. Following 8 weeks of inhaled FP, there was a significant improvement in the mean dyspnoea score during breathing against resistance in the asthmatics receiving IGCs but not in the control group (P<005). In the study group 32 patients had an improved FEV1 > 15% and 15 patients did not. There was a statistically significant difference in perception of dyspnoea (P<0.01), between the group of patients with a improved FEV1 and the group of patients that were under IGC treatment without improvement in their FEV1. There was also a difference in the mean beta2-agonists consumption between the two groups (P<0.01). Asthmatic patients have a significantly lower perception of dyspnoea compared to normal subjects. IGC treatment was associated with increased perception of dyspnoea. However, this improvement was noted only in patients with improved FEV1, while the patients without improvement remained with an equal degree of dyspnoea perception and beta2-agonists consumption.     

Use of a portable device to record maximum inspiratory flow in relation to dyspnoea in patients with COPD

Forced inspiratory measures have been described to reflect the reduction in dyspnoea upon bronchodilation in severe COPD. Based on this we evaluated the applicability and usefulness of a portable device for the assessment of forced inspiration. In 37 patients with COPD (GOLD II/II/IV n = 16/15/6, mean ± SD FEV(1) 46.2 ± 15.4%pred) lung function was recorded prior to inhalation of 24 μg formoterol and 30 min later. Assessments comprised spirometry including forced inspiration, body plethysmography, maximum inspiratory flow (InCheck, Clement Clarke), and changes in dyspnoea via visual analogue scale (VAS). The sequence was repeated on a second day to assess reproducibility. Bronchodilation by formoterol was detectable in all functional indices (p < 0.05 each) except total lung capacity. FEV(1) improved by (mean ± SD) 11.1 ± 10.3%, forced inspiratory volume in 1s (FIV(1)) by 11.6 ± 13.5%, inspiratory peak flow (PIF) by 10.7 ± 16.2%, and inspiratory flow determined by the InCheck device (IF-IC) by 11.9 ± 14.4%. Remarkably, the changes of IF-IC (p < 0.001) but not those of other measures except FIV(1) (p < 0.05) were related to those of dyspnoea. Effects on IF-IC showed reproducibility comparable to that of other indices. The results suggest that a simple, portable device for recording forced inspiration could be useful in monitoring COPD, as a functional correlate of acute changes in dyspnoea.     

有创与无创序贯机械通气治疗慢性阻塞性肺疾病重症呼吸衰竭

目的探讨有创与无创序贯机械通气治疗慢性阻塞性肺疾病（COPD）重症呼吸衰竭的方法与疗效。方法对40例COPD重症呼吸衰竭患者进行气管插管机械通气治疗，达到肺部感染控制窗（PIG窗）后，随机分为序贯治疗组和对照组，每组20例。序贯组治疗方法：立即拔出气管插管，改用口鼻面罩双水平气道正压通气（BiPAP）。对照组治疗方法：继续按常规有创机械通气方法治疗，以目前临床常用压力支持通气（PSV）模式脱机、2组同时进行监护，观察2组患者有创通气时间、呼吸机相关肺炎（VAP）发生例数、总机械通气时间、住院时间、监护时间、病死率等。结果2组患者发生VAP的例数分别为1例（5％）和8例（40％）（P〈0．05），总机械通气时间分别为（10．4±2．5）d和（15．3±3．2）d（P〈0．05），住院时间分别为（16．2±2．8）d和（25．8±4．2）d（P〈0．01）。结论在PIC窗指导下的有创与无创序贯性通气治疗方法，可以明显缩短机械通气时间，降低VAP发生率，缩短重症监护（ICU）和总住院时间，改进治疗效果，降低治疗费用，提高抢救成功率。     

Oral iron chelator deferasirox in the treatment of secondary hemochromatosis following bone marrow transplantation in a patient with severe aplastic anemia

Iron overload sometimes complicates the clinical course of bone marrow transplantation and can cause damage to liver and heart function. A patient with post-transplantation secondary hemochromatosis was treated with deferasirox, which not only normalized ferritin levels, but also reduced hepatic iron to normal values as measured by biosusceptometry with a superconducting quantum interference device. Side effects were minimal. The use of deferasirox to reduce post-transplant iron burden merits evaluation in a larger patient population.     

Dyspnoea with activities of daily living versus peak dyspnoea during exercise in male patients with COPD

Dyspnoea measurements in chronic obstructive pulmonary disease (COPD) can be broadly divided into two categories: those that assess breathlessness during exercise, and those that assess breathlessness during daily activities. We investigated the relationships between dyspnoea at the end of exercise and during daily activities with clinical measurements and mortality in COPD patients. We examined 143 male outpatients with moderate to very severe COPD. The peak Borg score at the end of progressive cycle ergometry was used for the assessment of peak dyspnoea rating during exercise, and the Baseline Dyspnea Index (BDI) score was used for dyspnoea with activities of daily living. Relationships between these dyspnoea ratings with other clinical measurements of pulmonary function, exercise indices, health status and psychological status were then investigated. In addition, their relationship with the 5-year mortality of COPD patients was also analyzed to examine their predictive ability. Although the BDI score was significantly correlated with airflow limitation, diffusing capacity, exercise indices, health status and psychological status, the Borg score at the end of exercise had non-existent or only weak correlations with them. The BDI score was strongly significantly correlated with mortality, whereas the Borg score was not. Dyspnoea during daily activities was more significantly correlated with objective and subjective measurements of COPD than dyspnoea at the end of exercise. In addition, the former was more predictive of mortality. Dyspnoea with activities of daily living is considered to be a better measurement for evaluating the disease severity of COPD than peak dyspnoea during exercise.     

Depression in the patient with COPD

This paper explores the recent literature surrounding comorbid depression and COPD. The literature reveals a high prevalence of depression in patients with COPD and some evidence that the depression is a result of the disease. The literature highlights the negative impact of depression on quality of life and a possible impact on mortality. Depression also negatively impacts on compliance and smoking cessation. Treatment of depression in COPD, particularly by cognitive behavioral therapy, has positive impact on quality of life. Tricyclic antidepressants have a positive impact on mood and COPD, but side effects limit their use. The advent of the new antidepressants may improve acceptability and outcomes, but the research is yet to be undertaken. Physical rehabilitation may have a positive impact on mood. This paper highlights the difficulty in screening for depression in patients with COPD due to the overlap of symptoms between the two diseases. Despite the difficulties, it is important to recognize and treat depression in patients with COPD because of the significant likelihood of improvement in quality of life.