The diagnosis and treatment of elderly patients with acute exacerbation of chronic obstructive pulmonary disease and chronic bronchitis.

The syndrome of chronic obstructive pulmonary disease (COPD) consists of chronic bronchitis (CB), bronchiectasis, emphysema, and reversible airway disease that combine uniquely in an individual patient. Older patients are at risk for COPD and its components--emphysema, CB, and bronchiectasis. Bacterial and viral infections play a role in acute exacerbations of COPD (AECOPD) and in acute exacerbations of CB (AECB) without features of COPD. Older patients are at risk for resistant bacterial organisms during their episodes of AECOPD and AECB. Organisms include the more-common bacteria implicated in AECOPD/AECB such as Haemophilus influenzae, Moraxella catarrhalis, and Streptococcus pneumoniae. Less-common nonenteric, gram-negative organisms including Pseudomonas aeruginosa, gram-positive organisms including Staphylococcus aureus, and strains of nontuberculosis Mycobacteria are more often seen in AECOPD/AECB episodes involving elderly patients with frequent episodes of CB or those with bronchiectasis. Risk-stratified antibiotic treatment guidelines appear useful for purulent episodes of AECOPD and episodes of AECB. These guidelines have not been prospectively validated for the general population and especially not for the elderly population. Using a risk-stratification approach for elderly patients, first-line antibiotics (e.g., amoxicillin, ampicillin, pivampicillin, trimethoprim/sulfamethoxazole, and doxycycline), with a more-limited spectrum of antibacterial coverage, are used in patients who are likely to have a low probability of resistant organisms during AECOPD/AECB. Second-line antibiotics (e.g., amoxicillin/clavulanic acid, second- or third-generation cephalosporins, and respiratory fluoroquinolones) with a broader spectrum of coverage are reserved for patients with significant risk factors for resistant organisms and those who have failed initial antibiotic treatment

Patient considerations in the treatment of COPD: focus on the new combination inhaler umeclidinium/vilanterol.

Medication adherence among patients with chronic diseases, such as COPD, may be suboptimal, and many factors contribute to this poor adherence. One major factor is the frequency of medication dosing. Once-daily dosing has been shown to be an important variable in medication adherence in chronic diseases, such as COPD. New inhalers that only require once-daily dosing are becoming more widely available. Combination once-daily inhalers that combine any two of the following three agents are now available: 1) a long-acting muscarinic antagonist; 2) a long acting beta2 agonist; and 3) an inhaled corticosteroid. A new once-daily inhaler with both a long-acting muscarinic antagonist, umeclidinium bromide, and a long acting beta2 agonist, vilanterol trifenatate, is now available worldwide for COPD treatment. It provides COPD patients convenience, efficacy, and a very favorable adverse-effects profile. Additional once-daily combination inhalers are available or will soon be available for COPD patients worldwide. The use of once-daily combination inhalers will likely become the standard maintenance management approach in the treatment of COPD because they improve medication adherence

The Integration of biomimicry into a built environment design process model: An alternative approach towards hydro-infrastructure

Current methods and processes that support the planning, design and construction of a sustainable built environment include ambiguous principles (Roseland 2000), lack feedback loops (Van Bueren and Jong 2007) and lack a common language between disciplines (Brandon et al 1997). As a result of 3.8 billion years of research and development (evolution), nature provides a set of design blueprints that may be used to guide us to create elegant, sustainable, and innovative designs for human technologies (Benyus 1997). The field of biomimicry analyzes nature\u27s best ideas and adapts them for human use (Benyus 1997). The built environment could benefit from the integration of a discipline such as biomimicry into the design process. One example within the built environment where the field of biomimicry might offer sustainable practices is that of human hydro-infrastructure, since many systems are approaching the end of their useful life (Mays 2002, AWWA 2001). Hydro-infrastructure includes the management of water systems in order to support human civilization. This thesis integrates the field of biomimicry into a design process model that supports the built environment. The design process model proposed in this paper allows a further distillation of components (functions) in order to seek organism strategies that accomplish the same function. These strategies are then translated into conceptual design options applicable to various scales within human hydro-infrastructure. Integrating biomimicry\u27s Life\u27s Principles into a built environment process model, will make biomimicry more accessible and thus more widely accepted throughout the industry, and the sustainability of all species will benefit

The Asthma-COPD Overlap Syndrome: A Common Clinical Problem in the Elderly

Many patients with breathlessness and chronic obstructive lung disease are diagnosed with either asthma, COPD, or—frequently—mixed disease. More commonly, patients with uncharacterized breathlessness are treated with therapies that target asthma and COPD rather than one of these diseases. This common practice represents the difficulty in distinguishing these disorders clinically, particularly in patients with a history that does not easily differentiate asthma from COPD. A common clinical scenario is an older former smoker with partially reversible or fixed airflow obstruction and evidence of atopy, demonstrating “overlap” features of asthma and COPD. We stress that asthma-COPD overlap syndrome becomes more prevalent with advancing age as patients respond less favorably to guideline-recommended drug therapy. We review the similarities and differences in clinical characteristics between these disorders, and their physiologic and inflammatory profiles within the context of the aging patient. We underscore the difficulties in differentiating asthma from COPD in current or former smokers, share our institutional experience with overlap syndrome, and highlight the need for new research to better characterize and investigate this important clinical phenotype

Multiple Organ Transplantation after Suicide by Acetaminophen and Gunshot Wound

Emergency physicians (EP) and medical toxicologists are integral in identifying and treating patients with overdoses. Transplant centers are expanding acceptance criteria to consider those with poison-related deaths. We present a case of a simultaneous gunshot wound to the head and an acetaminophen overdose. This case highlights the importance of EPs and medical toxicologists in recognizing the medical complexity of suicides, optimizing treatment, and timing of organ procurement. Early antidote administration and aggressive supportive care allowed the patient to be evaluated as a potential donor. EPs and medical toxicologists have integral roles in overdose patients as organ donors

Rozpoznawanie i leczenie zaostrzeń przewlekłej obturacyjnej choroby płuc i przewlekłego zapalenia oskrzeli u chorych w podeszłym wieku

Na zespół przewlekłej obturacyjnej choroby płuc (POChP) składają się przewlekłe zapalenie oskrzeli (PZO), rozstrzenie oskrzeli, rozedma i odwracalne zmiany w drogach oddechowych, które tworzą swoiste połączenia u poszczególnych chorych. Chorzy w podeszłym wieku są narażeni na ryzyko zachorowania na POChP i jej składowe — rozedmę, PZO i rozstrzenie oskrzeli. Zakażenia bakteryjne i wirusowe odgrywają rolę w zaostrzeniach POChP i w zaostrzeniach PZO bez cech POChP. Chorzy w podeszłym wieku podczas epizodów zaostrzeń POChP i PZO są narażeni na ryzyko działania opornych bakterii, do których należą często stwierdzane w zaostrzeniach POChP i PZO między innymi Haemophilus influenzae, Moraxella catarrhalis i Streptococcus pneumoniae. Rzadziej spotykane niejelitowe bakterie Gram-ujemne, w tym Pseudomonas aeruginosa, bakterie Gram-dodatnie, w tym Staphylococcus aureus, i szczepy niegruźliczych mykobakterii są częściej stwierdzane w zaostrzeniach POChP/PZO u chorych w podeszłym wieku z częstymi epizodami PZO lub u pacjentów z rozstrzeniami oskrzeli. Wytyczne dotyczące leczenia antybiotykami w zależności od stopnia ryzyka wydają się użyteczne w przypadku ropnych zaostrzeń POChP i w zaostrzeniach PZO. Wytyczne te nie zostały prospektywnie potwierdzone dla ogólnej populacji ani w odniesieniu do grupy osób w podeszłym wieku. Posługując się stratyfikacją ryzyka dla chorych w podeszłym wieku, antybiotyki pierwszego rzutu (np. amoksycylina, ampicylina, piwampicylina, trimetoprim/sulfametoksazol i doksycyklina) z bardziej ograniczonym spektrum antybakteryjnym stosuje się u chorych, u których prawdopodobieństwo stwierdzenia w czasie zaostrzeń POChP/PZO opornych bakterii jest mniejsze. Antybiotyki drugiego rzutu (np. amoksycylina/ /kwas klawulanowy, cefalosporyny II lub III generacji i fluorochinolony stosowane w zakażeniach układu oddechowego) o szerszym spektrum działania są zarezerwowane dla chorych z istotnymi czynnikami ryzyka zakażenia opornymi drobnoustrojami i tych pacjentów, u których początkowe leczenie antybiotykami się nie powiodło. Medycyna Wieku Podeszłego 2011, 1 (1), 1–1

Metoprolol treatment of dual cocaine and bupropion cardiovascular and central nervous system toxicity

Cardiovascular and central nervous system (CNS) toxicity, including tachydysrhythmia, agitation, and seizures, may arise from cocaine or bupropion use. We report acute toxicity from the concomitant use of cocaine and bupropion in a 25-year-old female. She arrived agitated and uncooperative, with a history of possible antecedent cocaine use. Her electrocardiogram demonstrated tachycardia at 130 beats/min, with a corrected QT interval of 579 ms. Two doses of 5 mg intravenous metoprolol were administered, which resolved the agitation, tachydysrhythmia, and corrected QT interval prolongation. Her comprehensive toxicology screen returned positive for both cocaine and bupropion. We believe clinicians should be aware of the potential for synergistic cardiovascular and CNS toxicity from concomitant cocaine and bupropion use. Metoprolol may represent an effective initial treatment. Unlike benzodiazepines, metoprolol directly counters the pharmacologic effects of stimulants without respiratory depression, sedation, or paradoxical agitation. A lipophilic beta-blocker, metoprolol has good penetration of the CNS and can counter stimulant-induced agitation

DNA polymerase δ-dependent repair of DNA single strand breaks containing 3′-end proximal lesions

Base excision repair (BER) is the major pathway for the repair of simple, non-bulky lesions in DNA that is initiated by a damage-specific DNA glycosylase. Several human DNA glycosylases exist that efficiently excise numerous types of lesions, although the close proximity of a single strand break (SSB) to a DNA adduct can have a profound effect on both BER and SSB repair. We recently reported that DNA lesions located as a second nucleotide 5′-upstream to a DNA SSB are resistant to DNA glycosylase activity and this study further examines the processing of these ‘complex’ lesions. We first demonstrated that the damaged base should be excised before SSB repair can occur, since it impaired processing of the SSB by the BER enzymes, DNA ligase IIIα and DNA polymerase β. Using human whole cell extracts, we next isolated the major activity against DNA lesions located as a second nucleotide 5′-upstream to a DNA SSB and identified it as DNA polymerase δ (Pol δ). Using recombinant protein we confirmed that the 3′-5′-exonuclease activity of Pol δ can efficiently remove these DNA lesions. Furthermore, we demonstrated that mouse embryonic fibroblasts, deficient in the exonuclease activity of Pol δ are partially deficient in the repair of these ‘complex’ lesions, demonstrating the importance of Pol δ during the repair of DNA lesions in close proximity to a DNA SSB, typical of those induced by ionizing radiation

Multicenter clinical trial of recombinant human insulin-like growth factor I in patients with acute renal failure

Multicenter clinical trial of recombinant human insulin-like growth factor I in patients with acute renal failure.BackgroundPatients with acute renal failure (ARF) have high morbidity and mortality rates, particularly if they have serious comorbid conditions. Several studies indicate that in rats with ARF caused by ischemia or certain nephrotoxins, insulin-like growth factor-I (IGF-I) enhances the recovery of renal function and suppresses protein catabolism.MethodsOur objective was to determine whether injections of recombinant human IGF-I (rhIGF-I) would enhance the recovery of renal function and is safe in patients with ARF. The study was designed as a randomized, double-blind, placebo-controlled trial in intensive care units in 20 teaching hospitals. Seventy-two patients with ARF were randomized to receive rhIGF-I (35 patients) or placebo (37 patients). The most common causes of ARF in the rhIGF-I and placebo groups were, respectively, sepsis (37 and 35% of patients) and hypotension or hemodynamic shock (42 and 27% of patients). At baseline, the mean (± sd) APACHE II scores in the rhIGF-I and placebo-treated groups were 24 ± 5 and 25 ± 8, respectively. In the rhIGF-I and placebo groups, the mean (median) urine volume and urinary iothalamate clearances (glomerular filtration rate) were 1116 ± 1037 (887) and 1402 ± 1183 (1430)ml/24hr and 6.4 ± 5.9 (4.3) and 8.7 ± 7.2 (4.4)ml/min and did not differ between the two groups. Patients were injected subcutaneously every 12hours with rhIGF-I, 100 μg/kg desirable body weight, or placebo for up to 14days. Injections were started within six days of the onset of ARF. The primary end-point was a change in glomerular filtration rate from baseline. Other end points included changes from baseline in urine volume, creatinine clearance and serum urea, creatinine, albumin and transferrin, frequency of hemodialysis or ultrafiltration, and mortality rate.ResultsDuring the treatment period, which averaged 10.7 ± 4.1 and 10.6 ± 4.5days in the rhIGF-I and placebo groups, there were no differences in the changes from baseline values of the glomerular filtration rate, creatinine clearance, daily urine volume, or serum urea nitrogen, creatinine, albumin or transferrin. In patients who did not receive renal replacement therapy, there was also no significant difference in serum creatinine and urea between the two groups. Twenty patients in the rhIGF-I group and 17 placebo-treated patients underwent dialysis or ultrafiltration. Twelve rhIGF-I–treated patients and 12 placebo-treated patients died during the 28days after the onset of treatment.ConclusionsrhIGF-I does not accelerate the recovery of renal function in ARF patients with substantial comorbidity