A 71-year-old man was admitted from a nursing home to the medical service with a one-week history of fever, deteriorating level of consciousness, and inability to take adequate fluid. Two months previously he had suffered a stroke and since that time had required nursing care due to inability to communicate anddifficulty swallowing. His medications at the nursing home included cimetidine (Tagamet), 300 mg daily, and multivitamins, one tablet daily.
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Canadian Neighbor Pharmacy: Imposed Pursed-Lips Breathing on Respiratory Mechanics and Dyspnea at Rest and During Exercise in COPD
Eight patients (2 women and 6 men) with stable mild-to-severe COPD participated in the study (Table 1). Subjects with known cardiovascular disease, neurologic or psychiatric illness, or impaired lower extremity function or those requiring supplemental oxygen were excluded from the study. All patients received their regular treatment of inhaled bronchodilators, and none received oral steroid therapy. Four of the patients were receiving inhaled steroid therapy, and one patient was receiving oral theophylline therapy. No change in the medications was made for the purpose of the study. Patients were asked to abstain from smoking on the day of the study and to avoid eating for at least 2 h prior to undergoing testing. The study was approved by the ethics committee of the hospital, and all subjects gave written informed consent.
Protocols and Instrumentation
One week prior to the actual study, subjects underwent pulmonary function testing (system 1085; Medical Graphics Corp; St. Paul, MN) and performed an incremental exercise test on a bicycle ergometer (model 400L; Medical Fitness Equipment; Maarn, the Netherlands) to determine their maximum exercise workload (WLmax). Subjects maintained a mean (± SD) pedaling rate of 60 ± 5 revolutions per minute, and workload was increased by 10 W every minute until subjects could no longer continue. During this initial session, a physiotherapist instructed subjects on how to perform the PLB technique (ie, nasal inspiration followed by expiratory blowing against partially closed lips avoiding forceful expiration), and subjects also practiced the technique while pedaling and wearing a tight-fitting facemask in order to familiarize them with the study protocol. None of the subjects had difficulty in learning the breathing technique.
This study confirms the results of previous studies on truth disclosure in a more realistic clinical setting. The patients in the current study did not have a previous diagnosis of cancer and were facing the real uncertainties of hospital admission and investigation; they were aware that their preferences would be recorded and acted on if necessary. The vast majority of patients in this study wanted to be told of a serious diagnosis and most wanted full details of their condition. Somewhat surprisingly, a clear majority of patients preferred to be alone rather than with their family when told of bad news. This is contrary to the findings of other workers. Subsequently, doctors were able to comply with patients’ wishes in almost all cases.
Individual people have specific informational needs that can only be identified by asking the individual. Respecting patient autonomy means that we should attempt to identify those who would prefer less information rather than adopting a policy of full automatic disclosure. This is consistent with the wishes expressed by patients in other studies. However, it is important that the desire to protect such patients should not lead to a lack of candor with the majority of patients who do want to know about their diagnosis. This study confirms that seeking preferences regarding truth disclosure at the outset of hospitalization is helpful and feasible in everyday practice and that the results can be used by clinicians to improve communication with patients and families in accordance with patients’ own wishes. Discussions about treatment options may mandate the disclosure of the diagnosis in some cases, and it could be argued that it is inappropriate to offer such patients the option of not receiving information, However, most of the patients who would prefer not to know of a serious condition would accept being told if that were required to provide effective treatment.
Canadian Health and Care Mall: Mitral Valve E-Point Septal Separation as an Indicator of Ejection Fraction
The mitral valve E-point septal separation (EPSS) is widely used clinically as an M-mode echocardio-graphic indicator of a normal or abnormal left ventricular ejection fraction. However, no study has examined systematically the utility of the EPSS in predicting normality of ejection fraction in patients with reversed septal motion which is often observed in patients with right ventricular volume overload states or right ventricular disease (either primary or due to pulmonary disease). If valid, this measurement would have significant clinical importance because other conventional M-mode echocardiographic correlates of ejection fraction, such as fractional shortening, are not useful in patients with reversed septal motion. Therefore, the purpose of this study was to compare the utility of the EPSS as an indicator of a normal or abnormal ejection fraction in patients with normal and reversed septal motion.
Despite the widespread use of β 2-agonists, their safety has been questioned. Several studies have reported an increased incidence of cardiac arrhythmias in patients treated with these agents, and other studies found an increased cardiovascular death with the use of oral and nebulized β2-agonists. Although no causal relationship has been demonstrated, the possible arrhythmogenic effects of these drugs place them under considerable suspicion. Clarifying the effects of β2-agonists on myocardial conduction and refractoriness could provide a significant insight into the potential arrhythmogenic role of these agents. This study is the first to evaluate the cardiac electrophysiologic effects of a single, regular dose of an inhaled β 2-agonist in humans. Salbutamol was selected, as it is one of the most widely used inhaled β2-agonists and would ensure improved correlation with standard clinical practice. The main finding of this study is that the inhalation of a standard dose of the β2-agonist salbutamol results in significant changes of cardiac electrophysiologic properties.
We found that inhalation of a single regular dose of salbutamol significantly enhanced AV nodal conduction, as reflected by shortening of the AH interval and decreased atrial and ventricular refractoriness without any remarkable effect on His-Purkinje conduction. The refractoriness of the AV node was also decreased, as indicated by shortening of the atrial pacing cycle length that resulted in AV node Wenckebach block. In addition, inhaled salbutamol produced a significant increase in heart rate and shortened the SNRT.
However, our findings cannot be interpreted on the basis of changes in heart rate. Since all refractory periods were determined at the same drive cycle length (both 500 ms and 400 ms), the observed changes in refractory periods are independent of the underlying heart rate and indicate the effects of salbutamol on myocardial conduction and refractoriness. Moreover, we found a shortening of the AH interval after the inhalation of salbutamol, which seems to be due to the effect of the drug, as the AH interval normally decreases with a sympathetic driven heart rate increase. The source: canadian health care mall gives you an opportunity to enter the world of medicine and pharmacy.
Upper airway resistance syndrome (UARS) is a recently described form of sleep-disordered breathing that may result in excessive daytime sleepiness (EDS). UARS is defined by repetitive increases in upper airway resistance (IUAR) associated with brief EEG arousals. The diagnosis requires demonstration of IUAR in a crescendo pattern of negative inspiratory pressures on esophageal manometry. We used a negative inspiratory pressure of < — 12 cm H2O in scoring these studies. The resulting arousals are followed by normalization of Pes. However, esophageal manometry is not commonly employed, making UARS difficult to diagnose definitively. Clinicians often make the diagnosis presumptively based on the presence of crescendo snoring associated with respiratory effort-related arousals (RERAs). Limited use of esophageal manometry may underdiagnose UARS and may lead to misclassification of a patient’s hypersomnolence. This misdiagnosis may, in turn, result in the inappropriate use of stimulants as a potential treatment of EDS. These therapies may be ineffective or may mask the underlying sleep disorder.
Although difficult to diagnose, UARS is suggested by EDS associated with snoring in patients who do not demonstrate apneic or hypopneic respiratory events on polysomnography. However, patients may manifest sleep-disordered arousals consistent with UARS even in the absence of snoring, which we define as silent UARS (SUARS). The purpose of this article is to report the occurrence and prevalence of SUARS in our population.
While a majority of lung cancer patients have a history of tobacco use, the variation in lung cancer risk among smokers can be 20-fold. One well-documented host factor related to the risk of lung cancer is COPD, including emphysema and chronic bronchitis. COPD shares common etiologic factors with lung cancer, particularly cigarette smoking. Previous studies have suggested that a1-antitrypsin deficiency (A1ATD) not only can cause emphysema but is also associated with an increased risk of multiple malignancies, including lung cancer. Several mechanisms of tumorigenesis have been postulated between A1ATD and lung cancer development, as follows: excess neutrophil elastase, the counterpart of a1-antitryp-sin, may facilitate cancer development by causing tissue damage and air trapping that fosters longer carcinogen exposure; may promote cancer progression by degrading the intercellular matrix barrier; and may lead to cancer development through the tumor necrosis factor signaling pathway. To test the hypothesis that a1-antitrypsin and neutrophil elastase may be critical in the causal pathway from tobacco smoke exposure to lung cancer development, we conducted a case-control study using functionally significant polymorphic markers to assess the role of protease inhibitor-1 (PI1) and neutrophil elastase-2 (ELA2), which encode functional variations of the two proteins in lung cancer risk in concert with known environmental and host factors.
HBEGF-Stimulated JAR Cell Migration Is Mediated by HER1 and the PI3K Pathway
JAR cell migration assays were conducted using increasing concentrations of HBEGF as chemoattractant in the lower well of a transwell migration assay. HBEGF stimulated a dose-dependent and significant 3- to 6-fold increase in migrated JAR cells at 10 and 100 ng/ml (Fig. 4A, P < 0.001; n = 4). Preincubation of the JAR cells with AG1478 resulted in complete inhibition of HBEGF-induced JAR cell migration (Fig. 4B, striped bar, P < 0.001). In contrast, preincubation of JAR cells with AG825 only had a partial inhibitory effect on HBEGF-mediated migration (Fig. 4B, shaded bar, P < 0.01; n = 4). To further assess the downstream effects of the signaling pathways involved in HBEGF-stimulated JAR cell migration, we preincubated JAR cells with a panel of signaling pathway inhibitors against the ERK and MAPK14 (p38), pKc, and PIK3 pathways for 30 min prior to and during 48-h exposure to HBEGF as the chemotactic stimulus in a migration assay. Only inhibition of the PIK3 pathway using 1 iM LY294002 (Fig. 4 C, bold striped bar, P < 0.001; n = 3) had a significant inhibitory effect on HBEGF-mediated JAR cell migration (gray bar; Fig. 4C). Continue reading
DCM and EGF Promote EVT Differentiation Through HER1-Dependent Mechanisms
The effect of DCM and 10 ng/ml EGF on HER isoform expression in JAR cells was examined using dual immunofluorescence. These data demonstrate that 24-h incubation with either DCM (Fig. 1C) or EGF (Fig. 1E) resulted in downregulation of HER1 (red) and upregulation of HER2 (green) expression as compared to SFM control (Fig. 1A). Coincubation of either DCM (Fig. 1D) or EGF (Fig. 1F) with the HER1 antagonist AG1478 inhibited this switch in HER expression. Incubation of the cells with AG1478 alone did not influence HER isoform expression (Fig. 2B; n = 3).
Using the placental villous explant model we show that after 4 days, culture control explants possess extensive EVT outgrowths that are marked by HLAG expression (Fig. 2A). These explants express high levels of HER1 in the villous cytotrophoblast and early proliferative EVT (Fig. 2D), while HER2 is undetectable (Fig. 2G). Treatment of placental villous explants with DCM resulted in the loss of HER1 expression in the EVT outgrowth (Fig. 2E) and upregulation of HER2 (Fig. 2H). Co-incubation of the explants with DCM plus AG1478 inhibited the switch in HER isoform such that cells of the placental villous outgrowth retained HER1 (Fig. 2F) and did not upregulate HER2 (Fig. 2I) as compared to DCM treatment alone. Negative controls using either mouse IgG or rabbit IgG showed no staining (Fig. 2, J and K; n = 3).
Western Blot Analysis
Serum-starved JAR cells were stimulated with either EGF or HBEGF (10 ng/ml) over a 4-h time course. Following treatment, cells were washed with ice-cold PBS and lysed using a Bio-Rad cell lysis kit according to the manufacturer’s instructions (Bio-Rad, Mississauga, ON). Equal amounts of JAR cell proteins per lane were analyzed by Western blot analysis. Briefly, 60 ig of total protein per sample were added to NUPAGE LDS sample buffer (Invitrogen) with 2.5% p-mercaptoethanol and boiled for 5 min. Proteins were run on precast 3%—8% Tris-Glycein gels (Invitrogen) and transferred to polyvinylidene fluoride membrane (Millipore) at 4°C overnight. Membranes were blocked with 5% nonfat milk in Tris-buffered saline with Tween (TBS-T; 10 mM Tris [pH 7.5], 100 mM NaCl, and 0.1% Tween 20) for 1 h at room temperature. Membranes were incubated with either rabbit polyclonal anti-phospho HER1, Tyr992, Tyr1045, Tyr1068, or anti-phospho p85 PIK3 (New England Biolabs, ON) at 4°C overnight, and then washed and incubated with anti-rabbit horseradish peroxidase (1:2000)-linked secondary antibody (New England Biolabs) for 1 h at room temperature. Membranes were then stripped and reprobed with antibodies against the respective nonphosphorylated antibody (anti-HER1 and Anti p85 PIK3, 1:1000; New England Biolabs). To further assess equal loading of protein samples, blots were stripped for a second time and reprobed with an antibody against the housekeeping protein p-actin (Abcam, Cambridge, MA). Antibody reactions were detected using Bio-Rad WesternC chemiluminescence detection kit (Bio-Rad), followed by detection of chemiluminescence and band analysis using the VersaDoc 6 gel documentation system and Quantity One Software (Bio-Rad).