Dyspnea, Obstruction, Smoking, Exacerbation Index, and Chronic Obstructive Pulmonary Disease Test Score: Correlation in Predicting Outcomes in Patients with Chronic Obstructive Pulmonary Disease Exacerbations

Objectives: Chronic obstructive pulmonary disease (COPD) being a disease with systemic consequences necessitate the use of multidimensional indices for a comprehensive assessment of the disease's impact including the future risk of exacerbations and mortality. To study the role of dyspnea, obstruction, smoking, and exacerbation (DOSE) index as a predictor of future disease severity and its correlation with chronic obstructive pulmonary disease test (CAT) score. Measurements and results: A total of 60 inpatients with COPD exacerbations were followed up for 6 months to record the number of exacerbations of COPD. The DOSE index and CAT score were calculated after stabilization within 48 hours of admission, at 1 week, and again at 6 months. The mean difference between DOSE index score at admission and at 1 week was 1.382 � 0.561 and at admission and at 6 months was 2.15 � 0.988, both being statistically significant (p < 0.001). A high DOSE index score (?4) was associated with a greater risk of 2 or more exacerbations [odds ratio (OR), 12 (3.09�.60) and risk estimate, 3.75 (1.53�17)]. For the prediction of exacerbations, the area under the curve (AUC) was larger for the DOSE index (0.854) than the global initiative for chronic obstructive lung disease (GOLD) stage (0.789), p < 0.001 for both. Furthermore, DOSE index correlated significantly with the CAT score, an established health status measure, at all stages of disease severity; at the onset of exacerbation (r = 0.719, p < 0.001), after stabilization at 1 week (r = 0.736, p < 0.001) and at 6 months (r = 0.884, p < 0.001). Conclusion: The DOSE index is a simple, practical multidimensional grading tool for assessing current symptoms, health status, and future risk in COPD and acts as a guide to disease management as its component items can be modified by interventions. Its correlation with CAT, a well-known score is a novel observation, which further corroborates the validity of the DOSE index.

Endomyocardial fibrosis.

We present a case report of a 26-year-old male from Bulandsahar, India. The patient presented with right heart failure. Evaluation revealed peripheral eosinophilia. An echocardiogram and MRI showed biventricular hypertrophy with obliteration of the ventricular apices, typical of endomyocardial fibrosis. This condition is rare in Bulandsahar, India.

Emerging role of vasopressin.

Ionotropic agents are frequently used in vasodilatory shock like conditions of septic or nonseptic origin. Conventional catecholamines such as norepinephrine are used at a very high dose with possibility of adverse effects in many patients. One often encounters refractoriness to these drugs. Infusion of vasopressin (VP) which is detectable at inappropriately low level in advanced phase of septic shock might allow withdrawal of catecholamines, as it maintains adequate mean arterial pressure (MAP), improves urine output and leaves perfusion of vital organs unhindered. Vasopressin has been found to be superior to epinephrine in animal models and some human trials, especially in patients with resistant ventricular fibrillation (VF) while doing cardiopulmonary resuscitation (CPR). Analogues of VP have also been used for diuresis in patients of hepatorenal syndrome.

The 2003 outbreak of Dengue fever in Delhi, India.

Dengue fever (DF) and Dengue hemorrhagic fever (DHF) are widespread in Southeast Asia. An outbreak of DF/DHF in Delhi in 2003 started during September, reached its peak in October-November, and lasted until early December. This study describes the clinical and laboratory data of the 185 cases of DF/DHF admitted to Lok Nayak Hospital, New Delhi. The mean age of the patients was 26 +/- 10 years. Fever was present in all the cases with an average duration of fever being 4.5 +/- 1.2 days with headache (61.6%), backache, (57.8%), vomiting (50.8%) and abdominal pain (21%) being the other presenting complaints. Hemorrhagic manifestations in the form of a positive tourniquet test (21%), gum bleeding and epistaxis (40%), hematemesis (22%), skin rashes (20%) and melena (14%) were also observed. Hepatomegaly and splenomegaly were observed in 10% and 5% of cases, respectively. Laboratory investigations revealed thrombocytopenia (with a platelet count of < 100,000/microl) in about 61.39% of cases, Leukopenia (WBC <3,000/mm2) and hemoconcentration (Hct >20% of expected for age and sex) were found in 68% and 52% of the cases, respectively. The mortality rate was 2.7%. Despite widespread measures taken to control outbreaks of DF, it caused major outbreaks. More stringent measures in the form of vector control, improved sanitation and health education are needed to decrease morbidity, mortality and health care costs caused by a preventable disease.

Effect of esmolol on oxidant status and antioxidant activity in acute myocardial infarction.

AIMS AND OBJECTIVES: The role of oxygen free radicals in reperfusion injury to the heart in myocardial infarction (MI) has been postulated. In this study, the clinical and antioxidant effects of esmolol, an ultra-short acting beta blocker in patients of acute MI was studied. MATERIAL AND METHODS: This was a randomized, double-blind, controlled, prospective study. Total 30 patients with acute MI were included. All patients were thrombolysed with streptokinase. Fifteen of these patients were randomly selected to receive esmolol while other 15 patients served as controls. The parameters compared at 0, 2 and 24 hours between the esmolol group and the controls were--malondialdehyde (MDA), superoxide dismutase (SOD) and glutathione peroxidase (GPX). RESULTS: Patients with MI had 5.16 times higher MDA level at 0 hours (20.34 +/- 6.12 nmol/ml vs. 3.94 +/- 0.70 nmol/ml, p < 0.0001) than MDA level in normal healthy population. At 2 hours, patients with MI had 5.71 times higher MDA level compared to normal healthy population (22.51 +/- 5.51 nmol/ml vs. 3.94 +/- 0.70 nmol/ml, p < 0.0001). A statistically significant difference in MDA levels at 2 and 24 hours was observed in MI patients given esmolol (mean change 2.06 +/- 5.39 nmol/ml vs. -4.47 +/- 6.93 nmol/ml, p = 0.009). Esmolol infusion also caused significant difference in GPX level at 2 hours compared to controls (23.79 + 14.68 U/gm Hb vs 38.3 +/- 8.95 U/gm Hb, p = 0.003). CONCLUSION: Free radical levels are raised in patients with MI which may contribute to reperfusion injury. The antioxidant action of esmolol was clearly observed by significant difference in MDA level and GPX sparing effect. Large scale clinical trials may establish conclusively role of beta blockers as antioxidants as adjuvant to thrombolytic therapy in MI.

Effects of exogenous vitamin E supplementation on the levels of oxidants and antioxidants in chronic obstructive pulmonary disease.

Oxidative stress has been recognized as a central feature of smoke induced chronic obstructive pulmonary disease (COPD). Imbalance between oxidant and antioxidant enzymes is also an established fact in these patients. But studies in regard to stable COPD patients and effect of vitamin E supplementation are lacking. Thirty patients with COPD were included in the study. Their baseline clinical examination, spirometry, plasma malondialdehyde (MDA), alpha-tocopherol and red blood cell superoxide dismutase (SOD) levels were mea sured. Twenty healthy non-smokers who were matched for age and sex served as controls. All the above parameters were repeated after 12 weeks of supplementation with 400 IU of vitamin E daily. The mean malondialdehyde levels in the patients at baseline were higher than controls (5.91 +/- 1.23 nmol/ml vs 4.55 +/- 1.51 nmol/ml, P = 0 001), so also was plasma alpha-tocopherol levels (P < 0 001), while SOD levels were lower in the patients compared to controls (1692 +/- 259 units g/Hb vs 2451 +/- 131 units g/Hb, P < 0 001). Exogenous vitamin E (400 IU per day) supplementation did not bring about any significant change in plasma alpha-tocopherol and SOD levels. The Pearson s co-efficient of correlation between the levels of MDA, vitamin E, SOD; and spirometric measurements were not significant either on day 1 or after 12 weeks of vitamin E supplementation. The present study shows that initially the plasma lipid peroxide (MDA) levels are high and antioxidants (alpha-tocopherol and SOD) are low in patients with COPD. Exogenous supplementation with vitamin E does not have any significant effect on the spirometric measurements though it brings down the levels of MDA showing attenuation of further damage. However, inclusion of larger number of patients and supple mentation with vitamin E for longer periods may throw more light on free radical injury and protective effects of antioxidants.

Chronic myeloid leukemia presenting with avascular necrosis of femur head.

We report the case of a 15 years girl in whom avascular necrosis (AVN) of right femur head was the presenting feature of chronic stable phase of chronic myeloid leukemia (CML). To date, only three case of CML with AVN have been reported. So, in view of rarity of this condition, a similar case of CML presenting as AVN of femur head is being reported.

Hyperinsulinemia in subjects with and without coronary artery disease: a preliminary study from North India.

BACKGROUND: Hyperinsulinemia has been associated with obesity, hypertension, diabetes, and coronary artery disease. However, it is not clear whether hyperinsulinemia by itself is a risk factor for coronary artery disease in the absence of obesity, diabetes, and hypertension. Therefore, we conducted a study to evaluate the role of hyperinsulinemia in coronary artery disease in the absence of diabetes, hypertension, and obesity. METHODS AND RESULTS: A total of 80 cases and 50 controls were studied. Only non-diabetic, normotensive, nonobese men (body-mass index < or = 25) were included. The presence of valvular heart disease or an acute coronary event in the past 6 weeks were exclusion criteria. Serum insulin levels were measured in fasting samples by ELISA assay. The mean fasting insulin was 17.0+/-16.5 microIU/ml and 13.3+/-12.9 microIU/ml in the control and study groups, respectively (reference range 1.5-15.6 microIU/ml). There was no significant association between coronary artery disease and the surrogate markers of insulin resistance, namely, fasting insulin (p value 0.367) and homeostasis model assessment of insulin resistance (p value 0.589). CONCLUSIONS: A high-normal fasting insulin level was present in non-diabetic, nonhypertensive, and nonobese men in the Indian population. We suggest that insulin resistance may not per se be an independent risk factor for coronary artery disease. It may be an innocent bystander in coronary artery disease in an obese, hypertensive, and diabetic population. However, due to our small sample size, further studies are required in this direction.

Reversible posterior leukoencephalopathy syndrome: a report of 2 cases.

Reversible posterior leukoencephalopathy syndrome (RPLE) is an increasingly recognised disorder, most commonly associated with malignant hypertension, toxaemia of pregnancy or the use of immunosuppressive agents. Two cases of RPLE syndrome occurring in the setting of accelerated hypertension and eclampsia are described. Both patients had seizures, altered sensorium and typical findings on neuroimaging. They had complete clinical and radiological recovery. The clinical course, pathophysiology and neuroimaging features of RPLE syndrome are discussed.

Microbial pattern of acute infective exacerbation of chronic obstructive airway disease in a hospital based study.

Chronic bronchitis is associated with acute exacerbation, most often infective in origin. In order to study the bacteriological profile in such cases a total of 58 patients were enrolled in this study from the chest clinic of our hospital. The male to female ratio was 2 to 1. Mean age of study group was 47 years. All patients had increased cough and sputum production. Barlett count, gram stain and sputum cultures were done for all patients. IgM and IgG antibodies for M. pneumoniae by ELISA were estimated in all cases. The etiological diagnosis could be established in 72% cases. S. pneumoniae (25.8%), P. aeruginosa (12%), Klebsiella sp (10.3%), B. catarrhalis (3.4%), S. aureus (1.7%) were isolated. Although M. pneumoniae was not cultured it was demonstrated serologically in 20% of cases. H. influenzae was not isolated in any case. The frequency of isolating an etiological agent increased with severity of dysponea.

Chronobiology and chronotherapy: current perspectives.

To summarise, one can say that with the time to come, chronotherapy might become the order of the day in treatment of many systemic diseases whether they are cardiovascular, respiratory, infectious etc. This approach will certainly help in better control of signs and symptoms while simultaneously protecting the individual from untoward side effects and providing them with a better quality of life.

A study of lipid peroxide and alpha tocopherol in acute myocardial infarction.

Thirty patients of acute myocardial infarction proven by electrocardiography (ECG) and enzymes were included in the study. All of them received streptokinase. A single lead showing the largest ST elevation, a proportional value for the shift in ST segment > or = 0.5 was taken as criteria for reperfusion. ECG was recorded at 0 hour, 3 hours and 72 hours. At the start of streptokinase and 3 hours after, marker of free radical activity malondialdehyde (MDA) and antioxidant alpha tocopherol was measured. Mean value of serum alpha tocopherol level at start of streptokinase (t0) 10.03 +/- 2.5 micrograms/ml and at (t3) 3 hours after streptokinase was 8.60 +/- 2.6 micrograms/ml (P < 0.001) and mean value of serum lipid peroxidation level was 6.86 +/- 2.92 nanomol/ml at t(o) and at t3 value was 8.4 +/- 3.88 (P < 0.012) in successfully reperfused patients. In unsuccessful reperfusion group serum alpha tocopherol level at t(o) was 8.89 +/- 2.55 micrograms/ml and at t3 8.23 +/- 2.9 micrograms/ml (p > 0.05). Serum lipid peroxidation level in the same group at t0 was 6.53 +/- 2.26 nanomol/ml and at t3 was 6.29 +/- 2.27 nanomol/ml (p > 0.05). The increase in free radical marker MDA and decrease in one of the important antioxidant alpha tocopherol suggest that free radicals are increased after coronary vessels open up. As a result reperfused patients may be at risk of free radical mediated injury which may deny him the full benefit of reperfusion.

Myoglobinuria and transient acute renal failure in a patient revealing hypothyroidism.

Muscle involvement in hypothyroidism commonly manifests as fatigue, myalgias, stiffness and slowed reflexes. We report a case of transient acute renal failure related to rhabdomyolysis and myoglobinuria in a 40 year old man that revealed the diagnosis of hypothyroidism with myopathy. The patient had proximal muscle weakness and tenderness, markedly raised muscle enzymes and deranged renal functions that normalised with thyroid replacement therapy. Hypothyroidism, though rare, should be considered a definite and authentic cause of rhabdomyolysis.

Lipid peroxide, beta-carotene and alpha-tocopherol in ischaemic stroke and effect of exogenous vitamin E supplementation on outcome.

30 patients with CT proven infarct presenting within 24 hours of the acute event were included in the study with 20 age and sex matched controls. On day 1 and day 15 of stroke, levels of plasma lipid peroxide (oxidant) and plasma alpha-tocopherol and beta carotene (antioxidant) were estimated. The patients were randomly assigned to two groups, one group receiving 300 mg/day of vitamin E for 15 days. Neurological examination was conducted according to Mathew scale on day 1 and day 15 and rehabilitation assessment was done at day 15 and at 6 weeks according to Barthel Index. On day 1, the mean value of plasma lipid peroxidation in controls was 4.97 +/- 1.44 nmol/ml and in stroke patients 5.89 +/- 1.56 nmol/ml (p < 0.05). The plasma beta-carotene in controls was 2.35 +/- 1.09 mg/L while in stroke patients was 1.07 +/- 0.55 mg/L (p < 0.001) and plasma alpha-tocopherol in control 9.74 +/- 2.76 micrograms/ml as compared to 7.57 +/- 2.92 micrograms/ml in stroke patients (p < 0.02). Initially the plasma lipid peroxide levels are high and antioxidant levels are low in patients of ischemic stroke. Exogenous vitamin E supplementation does not have any significant effect on early neurological outcome but it does bring about significant changes in subsequent recovery and rehabilitation of patients of stroke.