Decreased duration of emergency department treatment of chronic obstructive pulmonary disease exacerbations with the addition of ipratropium bromide to beta-agonist therapy

STUDY OBJECTIVES

To determine the benefit of the addition of ipratropium bromide to beta-agonist therapy of acute exacerbations of chronic obstructive pulmonary disease.

DESIGN

The trial was randomized and double blinded.

SETTING

The study was conducted in the emergency department of Parkland Memorial Hospital, a busy, inner-city, county hospital.

INTERVENTIONS

Patients were treated in the medicine emergency department with either the standard regimen of nebulized isoetharine, 0.5 mL of a 1% solution (5.0 mg) diluted to 2.0 mL with normal saline every hour (control group) or with the same regimen plus ipratropium bromide, 54 micrograms (three puffs) after the first isoetharine treatment and 36 micrograms (two puffs) after the second and fourth (experimental group). A placebo metered-dose inhaler used in the same manner as the ipratropium blinded the study to both the patients and medical personnel.

MEASUREMENTS AND MAIN RESULTS

The group treated with the addition of ipratropium (30) was discharged from the ED an average of 91 minutes (P less than .05) sooner than the control group (25) and required on the average one less isoetharine treatment (P less than .05). The pulmonary functions tested, forced expiratory volume in the first second, and the forced vital capacity were the same in the two groups initially and on discharge, as identical discharge criteria were used in each group.

CONCLUSION

The addition of ipratropium to standard beta-agonist treatment of chronic obstructive pulmonary disease exacerbations shortens the duration of treatment required in the ED.

Diagnosing early Lyme disease

The diagnostic value of clinical, culture, and serologic findings was studied prospectively in 41 patients with early Lyme disease. Fifteen patients had erythema chronicum migrans alone, and 26 had clinical evidence of disseminated infection, most commonly affecting the brain or meninges, other skin sites, lymph nodes, or joints. Of 40 blood cultures, only one, from a patient with disseminated infection, yielded spirochetes. One of 10 patients tested with localized infection had an elevated IgM response to the Lyme spirochete (200 units or greater) during acute disease. Two to three weeks after beginning antibiotic therapy, four of the 10 patients had elevated specific IgM or IgG responses (200 units or greater). Of the 22 patients tested with disseminated disease, 10 initially had elevated levels of specific IgM or IgG, and 12 had such responses by convalescence. Because of the low yield of cultures and the delay in the specific antibody response, recognition of the clinical picture remains very important in diagnosing early Lyme disease.

Recovery of Lyme disease spirochetes from patients

Since the summer of 1982, we have cultured patient specimens for Lyme disease spirochetes. Of 118 patients cultured, four specimens yielded spirochetes: two from blood, one from a skin biopsy specimen of erythema chronicum migrans (ECM), and one from cerebrospinal fluid. All four isolates appeared identical when examined with a monoclonal antibody. However, attempts to recover the spirochete from synovium or synovial fluid were unsuccessful. In addition, the organism could not be visualized in skin or synovial biopsy specimens using the avidin-biotin peroxidase complex detection system. Thus, the current yield in culturing spirochetes from patients is quite low, and it is not yet known whether the organism is still alive later in the disease when arthritis is present.

The antibody response in Lyme disease

We determined the antibody response against the Ixodes dammini spirochete in Lyme disease patients by indirect immunofluorescence and an enzyme-linked immunosorbent assay (ELISA). The specific IgM response became maximal three to six weeks after disease onset, and then declined, although titers sometimes remained elevated during later disease. Specific IgM levels correlated directly with total serum IgM. The specific IgG response, often delayed initially, was nearly always present during neuritis and arthritis, and frequently remained elevated after months of remission. Although results obtained by indirect immunofluorescence and the ELISA were similar, the ELISA was more sensitive and specific. Cross-reactive antibodies from patients with other spirochetal infections were blocked by absorption of sera with Borrelia hermsii, but titers of Lyme disease sera were also decreased. To further characterize the specificity of the humoral immune response against the I. dammini spirochete, 35S-methionine-labeled spirochetal antigens were identified by immunoprecipitation with sera from Lyme arthritis patients. These polypeptides had molecular weights of 62, 60, 47, 37, 22, 18, and 15 kDa, and were not recognized by control sera. We conclude that the ELISA, without absorption, is the best method to assay the humoral immune response in Lyme disease, and we have identified methionine-containing spirochetal polypeptides that may be important in Lyme arthritis.

Profile of Asphyxiated Babies at Tribhuvan University Teaching Hospital

Objective: To assess risk factors and outcome in the early neonatal period of babies who were asphyxiated at birth. Methodology: This was a retrospective study conducted at Tribhuvan University Teaching Hospital (TUTH) over a period of one year from 15th Feb 2007 to 14th Feb 2008. All the term babies who had Apgar score of less than < 6 at 1 minute of birth were included. Detailed maternal risk factors during pregnancy and labor were analyzed. The newborn babies who required admission in neonatal unit were again analyzed for development of hypoxic ischemic encephalopathy (HIE) and their outcome. Results: During the study period, out of 3594 term babies, 327 babies (9%) were asphyxiated. Of the total asphyxiated babies, 85% and 15% had moderate and severe asphyxia, respectively, at 1 minute of birth. Out of these asphyxiated babies, 51% and 7% had intrapartum and maternal risk factors, respectively. Intrapartum risk factors like meconium stained liquor, non-vertex presentation, and fetal heart rate abnormalities accounted for 4 fold risk of asphyxia. Of these babies, 26% required admission in nursery and 29% developed hypoxic ischemic encephalopathy. Among the admitted babies 6% expired, 2% left against medical advice and rest were discharged. Conclusion: Early identification and close monitoring of high risk mothers studies with maintaining partograph during labor will help to reduce neonatal asphyxia. Key words: Asphyxiated babies doi:10.3126/jnps.v29i1.1592 J. Nepal Paediatr. Soc. Vol.29(1) p.3-5

A Study of Early Neonatal Deaths at Kathmandu Medical College Teaching Hospital

Over 9 million deaths occur each year in the perinatal and neonatal periods globally. 98% of these deaths take place in the developing world. Nepal has a high neonatal mortality rate (NMR) of 38.6 per 1000 live births (2001). Two thirds of the newborn deaths usually occur in the first week of life (early neonatal death). Newborn survival has become an important issue to improve the overall health status and for achieving the millennium developmental goals of a developing country like Nepal. Aims and Objectives: This study was carried out to determine the causes of early neonatal deaths (ENND) at KMCTH in the two-year period from November 2003 to October2005 (Kartik 2060 B.S. to Ashoj 2062). Methodology: This is a prospective study of all the early neonatal deaths in KMCTH during the two-year study period. Details of each early neonatal death were filled in the standard perinatal death audit forms of the Department. Results: Out of the 1517 total births in the two-year period, there were 10 early neonatal deaths (ENND). Early neonatal death rate during the study period was 6.7 per 1000 live births and early neonatal death rate (excluding less than 1 kg) was 6.1 per 1000 live births The important causes of early neonatal deaths were extreme prematurity, birth asphyxia, congenital anomalies and septicaemia. During the study period, there was no survival of babies with a birth weight of less than 1 kg. Among the maternal characteristics, 80% of the mothers of early neonatal deaths were aged between 20-35 years. 50% of the mothers were primigravida. 50% of the mothers of ENNDs had delivered their babies by caesarean section.Discussion: Most of the early neonatal deaths were due to extreme prematurity. Birth asphyxia was the second most important cause of early neonatal deaths. 70% of ENNDs were among LBW babies. Prevention of premature delivery, proper management of very low birth weight babies and early detection and appropriate management of perinatal hypoxia have become important interventional strategies in reducing early neonatal deaths in KMCTH.Conclusion: Early neonatal mortality at KMCTH is fairly low. Good care during pregnancy, labour and after the birth of the baby has helped to achieve these results. Low cost locally made equipments were used to manage the sick newborns. Reduction of early neonatal deaths require more intensive care including use of ventilators, surfactant and parenteral nutrition and prevention of preterm births Key words: Early neonatal death (ENND), neonatal mortality   doi:10.3126/jnps.v27i2.1584 J. Nepal Paediatr. Soc. Vol 27(2), p.79-82

Rett Syndrome: A Case report

Rett syndrome (RS) is a severe neuro-developmental disorder leading to severe intellectual disability in females all around the world. A four-year-old girl from Kathmandu presented with classic features of Rett syndrome (RS), including developmental regression with dementia, loss of acquired speech and hand function, and stereotypic hand movements along with generalized tonic clonic convulsion. Key words: Rett Syndrome, Developmental Regression   DOI = 10.3126/jnps.v28i1.1401   J. Nepal Paediatr. Soc. Vol.28(1) p.17-19