"Broken heart syndrome": catecholamine surge or aborted myocardial infarction?

Takotsubo cardiomyopathy, also called transient left ventricular apical ballooning or "broken heart syndrome", is a cardiac condition that mimics the clinical presentation of acute coronary syndrome but without any evidence of obstructive atherosclerotic coronary artery disease. An episode of intense emotional or physiologic stress, serving as the nidus for a catecholamine surge, has been reported prior to presentation and is presumed to be the triggering factor playing the pathogenic role. We report a unique case of Takotsubo cardiomyopathy without any known precipitating factors. After reviewing multiple case reports and review articles, the evidence supporting a "catecholamine surge" is empirically plausible; however, our case calls this theory into question. The "aborted MI" hypothesis is more convincing as an all-inclusive nidus for the pathogenesis and clinical presentation described in Takotsubo syndrome. More detailed studies and research are needed to ascertain the pathogenesis and optimal management of this syndrome.     

Management of Australian Adults with Bronchiectasis in Tertiary Care: Evidence-Based or Access-Driven?

Lung - Australian data regarding the management of patients with bronchiectasis is scarce. We sought to compare the management of adults with bronchiectasis attending tertiary Australian centres...     

Bronchiectasis in children: Orphan disease or persistent problem?*

More than a decade ago, bronchiectasis unrelated to cystic fibrosis was termed an "orphan disease", because it had become an uncommon clinical entity among children in the developed world. Bronchiectasis is more common among children in lower socioeconomic classes and in developing countries, presumably due to more frequent and recurrent respiratory infections, environmental airway irritants, poor immunization rates, and malnutrition. Reports from the Southern Pacific and from Alaska Native children reveal persistently high rates of childhood bronchiectasis. Better epidemiologic data throughout the world are needed to reassess the importance of this condition. The pathophysiology includes airway inflammation, mucus production, and regional airway obstruction, yet the reasons why some children develop bronchiectasis while other do not is unclear. The coexistence of asthma with bronchiectasis is associated with more severe disease, yet the impact of asthma therapy in children with both disorders has not been studied. Similarly, the pattern of antibiotic use for children with bronchiectasis varies by region with little data to justify one particular approach. It may be that public health measures aimed at improving living conditions for children and prevention of respiratory infections with antiviral vaccines will have more impact on childhood bronchiectasis than medical treatments in the future.     

Evaluating Success of Therapy for Bronchiectasis: What End Points to Use?

Long-term treatment goals of bronchiectasis frequently include limiting the bacterial burden and inflammatory insult in the airways with the aim of improving symptoms, reducing exacerbation frequency and severity, and improving health-related quality-of-life. However, few clinical or laboratory markers specifically validated for bronchiectasis exist, and how best to assess the disease and its response to treatment is poorly understood. Pertinent, reliable markers are urgently needed to facilitate effective treatment of bronchiectasis and to ensure ongoing development of future therapies. This article explores the utility of potential end points in evaluating therapies used in the long-term management of stable bronchiectasis.     

Neutrophil Elastase Gene Polymorphisms: Modulators of Response to Therapy in Childhood Bronchiectasis?

Background

The aim of this study was to investigate polymorphisms in the promoter region of the neutrophil elastase (ELANE) gene as potential modulators of the therapeutic response in children with idiopathic bronchiectasis.

Methods

The study included 48 children between 5 and 17 years old who were diagnosed with idiopathic bronchiectasis based on high-resolution computed tomography of the thorax. In all patients therapy included administration of antibiotics, anti-inflammatory drugs, expectorants, and postural drainage. Response to therapy was evaluated by the change in FeNO levels before and after administration of therapy. The ELANE promoter region polymorphisms were analyzed by PCR-direct DNA sequencing.

Results

According to the predicted activity of ELANE genotypes, subjects were divided into two groups: low/intermediate activity (n = 18) and high activity (n = 30). Subjects in the group with high-activity genotype had higher initial FeNO levels and this difference was statistically significant (t = 2.906; p = 0.006). The difference between FeNO levels before and after therapy was also statistically significantly higher in children with high-activity genotype (t = 3.329; p = 0.002). Statistically significant correlation was observed between the change in FeNO levels and ELANE genotypes (r = 0.350; p = 0.015).

Conclusion

Children with high-activity genotype had higher initial FeNO levels and showed better response to therapy than children with low/intermediate-activity genotypes.     

Bedrails: restraints or enablers?

Bedrails presently are used as both mobility restraints and enablers in long-term care facilities. As enablers, bedrails facilitate movement and may reduce the risk of pressure ulcer development. As restraints, they impede movement and may increase risk of ulcer development. Omnibus Budget Reconciliation Act regulations on restraint use have led to confusion for state Medicare surveyors and facilities regarding the definition of appropriate bedrail use and need for supportive documentation. Consequently, some facilities receive deficiency citations for inappropriate use or documentation while others do not. The purpose of this survey was to compare responses of Directors of Nursing in long-term care facilities and Medicare state surveyors to determine how each interprets the Omnibus Budget Reconciliation Act bedrail language for use and documentation. Questionnaires on bedrail use and documentation were sent to state surveyors and Directors of Nursing. One hundred, three (103) Directors of Nursing in 45 states and 65 surveyors from 39 states participated in the survey (response rate 61%). Study results demonstrated general acceptance of bedrail use as an enabler but not as a restraint by both Directors of Nursing and state surveyors. Four percent (4%) of Directors of Nursing reported receiving a citation for bedrail use and 59% of surveyors reported issuing citations for bedrail use. Significant differences were noted between the two groups regarding appropriate bedrail use and necessary documentation. The intent of Medicare guidelines and the Centers for Medicare and Medicaid Services is to standardize care for nursing home residents in the United States; yet, current regulations are open to individual interpretation by state surveyors and confusion exists between the intent of the Omnibus Budget Reconciliation Act and the daily operations of nursing homes. Educating clinicians about the risks and benefits of bedrail use, either as restraint or enabler, and developing interventions and policies for appropriate use would be an important first step in resolving this issue.     

Endotoxin: friend or foe?

Endotoxin in our living environment has been of increasing interest to our global community of allergists. Initially and largely studied for its capacity to mediate septic shock (and earning its "-toxin" suffix), we have since come to understand that endotoxin in the dust of many occupational settings also is an occult respiratory culprit, inducing airflow obstruction and aggravating asthma and allergies. More recently, environmental endotoxin has been implicated as a microbial exposure in early childhood that may have an atopy-protective effect by augmenting early Th1-type immune development. Although seemingly paradoxical, endotoxin's dual nature ultimately may serve to enlighten our understanding of how such bioactive exposures can interact with and guide our immune systems in both health and disease.     

Intestine: organ or apparatus?

It is well known that human intestine is involved in different important functions. First of all, it is responsible for digestion and absorption of nutrients, electrolytes, water, bile salts and drugs, but it also has immunologic, endocrine and motor functions. Moreover, intestinal microflora, composed by a large diversity of bacterial cells, provides several beneficial functions for the host and is, nowadays, defined by many authors as an organ itself. In consideration of intestine complexity, we tried to understand if it can be considered only an organ or if it is an apparatus itself. We have analyzed the different components and their relationships, showing that a continuous collaboration is required among enterocytes, endocrine intestinal cells, gut immune system and microflora to assure an efficient mechanism of defense. In consideration of the complexity of intestinal components, together with the emergent role of microflora, we think that we could start to consider gut as a real apparatus, and not only as an organ.     

Noradrenaline: friend or foe?

Septic shock, systemic inflammation and pharmacological vasodilatation are often complicated by systemic hypotension despite aggressive fluid resuscitation and an increased cardiac output. If the physician wishes to restore arterial pressure to higher levels (> 80-85 mmHg), with the aim of sustaining cerebral and coronary perfusion pressure, the administration of systemic vasopressor agents, such as norepinephrine (noradrenaline), becomes necessary. However, because norepinephrine (NE) induces vasoconstriction in many vascular beds (visibly in the skin), it may decrease renal and visceral blood flow, impairing visceral organ function. This unproven fear deters clinicians from using NE more consistently. Vasodilated states, however, are often associated with impaired peripheral vascular responsiveness. In such states, unlike under normal circulatory conditions, NE may actually improve visceral organ blood flow by selectively increasing organ perfusion pressure. Data available from animal studies show that the increased organ perfusion pressures achieved with NE results in improved GFR and renal blood flow. In fact, recent sophisticated physiological analysis of its effects on the kidney shows that, even after controlling for the pressure effect, NE therapy is associated with an increase in renal blood flow after endotoxin administration. In particular, the renal Pzf (pressure at which there is no further blood flow) is decreased such that, at a constant pressure, renal blood flow increases after NE. There are no controlled human data to define the effects of NE on the kidney in the clinical context. However, many patient series have now been reported. They show a seemingly positive effect of NE administration on GFR and urine output. Our clinical experience in septic patients and cardiac patients with inflammatory or pharmacological vasodilatation is also positive. We have demonstrated a positive effect on coronary blood flow. There is no reason to fear the effect of NE. If it is used to support a vasodilated circulation after adequate intravascular filling has occurred and after a normal or increased cardiac output has been established, it is likely to be a friend not a foe.