Albuterol Inhaler Research Articles

Acute Bronchodilator Responsiveness in Bronchiolitis Obliterans Syndrome Following Hematopoietic Stem Cell Transplantation

The obstructive abnormality of bronchiolitis obliterans syndrome (BOS) after allogeneic hematopoietic stem cell transplantation (HSCT) is deemed to be virtually insensitive to treatment with inhaled bronchodilators. We studied whether nonconventional assessment of bronchodilation may help to detect physiologically meaningful airway responses missed by traditional criteria. Standard spirometry, partial and maximal expiratory flow-volume curves, and lung volumes were measured before and 90 min after inhalation of albuterol plus tiotropium in 17 patients who developed mild to very severe BOS following HSCT. After treatment with bronchodilators, the standard criteria of reversibility based on FEV1 and FVC were met in seven out of 17 patients. In eight patients, residual volume (RV) decreased beyond its within-session spontaneous variability, and functional residual capacity (FRC) was reduced in four of them. Partial forced expiratory flow (Vpart) increased beyond its within-session spontaneous variability in nine patients. Out of 10 patients in whom neither FEV1 nor FVC met the standard criteria of reversibility, six had a positive increase in Vpart or a decrease of lung hyperinflation (ie, FRC) or RV. In six patients with limited expiratory flow during tidal breathing, the postbronchodilator increase in Vpart was correlated with a decrease in FRC (R2=0.83; P=.011). This study suggests that airway smooth muscle tone plays a significant role in BOS after HSCT and that the common knowledge of BOS as an irreversible obstructive disease may stem from the limitation of simple spirometry to detect changes in small airways. ClinicalTrials.gov; No.: NCT01112241 (BOS-01); URL: www.clinicaltrials.gov.

Written Action Plan in Pediatric Emergency Room Improves Asthma Prescribing, Adherence, and Control

An acute-care visit for asthma often signals a management failure. Although a written action plan is effective when combined with self-management education and regular medical review, its independent value remains controversial. We examined the efficacy of providing a written action plan coupled with a prescription (WAP-P) to improve adherence to medications and other recommendations in a busy emergency department. We randomized 219 children aged 1-17 years to receive WAP-P (n = 109) or unformatted prescription (UP) (n = 110). All received fluticasone and albuterol inhalers, fitted with dose counters, to use at the discretion of the emergency physician. The main outcome was adherence to fluticasone (use/prescribed × 100%) over 28 days. Secondary outcomes included pharmacy dispensation of oral corticosteroids, β(2)-agonist use, medical follow-up, asthma education, acute-care visits, and control. Although both groups showed a similar drop in adherence in the initial 14 days, adherence to fluticasone was significantly higher over Days 15-28 in children receiving WAP-P (mean group difference, 16.13% [2.09, 29.91]). More WAP-P than UP patients filled their oral corticosteroid prescription (relative risk, 1.31 [1.07, 1.60]) and were well-controlled at 28 days (1.39 [1.04, 1.86]). Compared with UP, use of WAP-P increased physicians' prescription of maintenance fluticasone (2.47 [1.53, 3.99]) and recommendation for medical follow-up (1.87 [1.48, 2.35]), without group differences in other outcomes. Provision of a written action plan significantly increased patient adherence to inhaled and oral corticosteroids and asthma control and physicians' recommendation for maintenance fluticasone and medical follow-up, supporting its independent value in the acute-care setting. Clinical trial registered with www.clinicaltrials.gov (NCT 00381355).

Assessment of a Simplified Format of Written Patient Prescription Drug Information

Patients in the United States receive multiple forms of written information about their prescription medications. This pilot study was conducted to evaluate alternative formats of patient-directed written prescription information for four medications: cefaclor suspension, simvastatin tablets, albuterol inhaler, and capecitabine tablets. Fifty-four consumers evaluated this information using a 5-point satisfaction scale, responding to 10–12 questions, and participating in group discussion. Overall, consumers valued short, simple text, a question-answer format, a table layout, large font, adequate text spacing, bold type for emphasis, and easy-to-understand, actionable information that included impact statements on activities and lifestyle. This pilot study reveals that simplified prescription information with improved readability and reduced ambiguity may enhance consumer information retrieval and reinforce appropriate use of prescription medicines.

An elevated bronchodilator response predicts large airway inflammation in mild asthma

Exhaled nitric oxide (eNO) is elevated in asthmatics and is a purported marker of airway inflammation. The bronchodilator response (BDR) has also been shown to correlate with markers of airway inflammation, including eNO at 50 ml/sec (FE(NO,50)) which is comprised of NO from both the proximal and distal airways. Using eNO at multiple flows and a two-compartment model of NO exchange, the eNO signal can be partitioned into its proximal [J'aw(NO) (nl/sec)] and distal contributions [CA(NO) (ppb)]. We hypothesized that the BDR reflects the inflammatory status of the larger airways with smooth muscle, and thus would correlate with J'aw(NO). In 179 predominantly (95%) Hispanic children with mild asthma (69 steroid naïve), and 21 non-asthmatic non-atopic controls, spirometry and eNO at multiple flows were measured prior and 10 min following inhalation of albuterol. A trumpet-shaped axial diffusion model of NO exchange was used to characterize J'aw(NO) and CA(NO). The BDR correlated moderately (r = 0.44) with proximal airway NO (J'aw(NO)), but weakly (r = 0.26) with distal airway/alveolar NO (CA(NO)), and only in inhaled corticosteroid naïve asthmatics. A BDR cut point as low as >or=8% had a positive predictive value of 83% for predicting an elevated J'aw(NO) or FE(NO,50). We conclude that the BDR reflects inflammation in the large airways, and may be an effective clinical tool to predict elevated large airway inflammation.

An Unusual Dermatosis in a Child

A 9-year-old boy presented to the emergency room with various macular erythematoses and ecchymotic lesions with geometric shapes and well-defined edges on his left hand and forearm (Figure). Initially, the child denied that the lesions were self-inflicted. But during the anamnesis, his grandmother mentioned that she had noticed that her albuterol inhaler had run out before she had expected. We confirmed that the shape of the distal part of the inhaler corresponded exactly with the borders of the child's skin lesions.

Use of the inhaled corticosteroid to bronchodilator ratio in an audit of the treatment of asthma in an academic family medicine residency programme

Asthma affects around 5% of the United States population, with 50% having uncontrolled symptoms. To improve asthma care by seeing if the inhaled corticosteroid to bronchodilator ratio (RATIO) is associated with asthma control and if non-clinical factors were associated with adherence to asthma guidelines. A retrospective study using University of Oklahoma-Tulsa, School of Community Medicine Family Medicine Clinic electronic medical records of a random sample of 49 patients with asthma who were seen at least twice from July 2003 through June 2007 and did not have a diagnosis of chronic obstructive pulmonary disease or exercise-induced asthma. The RATIO for those prescribed corticosteroid inhalers was directly related to the actual step of asthma care (STEP) but inversely related to the number of prednisone courses prescribed per year (R2 =.30, p = 0.0012). The difference between the actual STEP and ideal STEP (had corticosteroid inhalers been prescribed for all the months in the study) was directly related to the percent of available salbutamol (albuterol) inhalersthat non-clinicians refilled and inversely related to the actual STEP (R2 = .45, p = 1.8 x 10(-5)). The available corticosteroid inhalers prescribed was directly related to the actual STEP and inversely related to the number of comorbid diagnoses addressed at the last asthma visit (R2 = .70, p = 5.8 x 10(-10)). Efforts to both limit salbutamol medications, especially by non-clinicians, and simultaneously prescribe appropriate amounts of inhaled corticosteroids, through a dedicated asthma visit, should improve asthma control. A higher RATIO implies better asthma control.

Intramuscular Air as a Complication of Pulse-Lavage Irrigation

Intramuscular air in the setting of infection can be an indicator of a rapidly escalating and potentially life-threatening infection, such as gas gangrene or necrotizing fasciitis. For a patient with diffuse pain in an extremity and air in the tissue planes as seen on imaging studies, surgical exploration has been strongly recommended1-6. Iatrogenic causes of air in fascial planes are underreported. We present the case of a child with septic arthritis of the hip that was treated with open irrigation and debridement by the on-call service. There was temporary use of pulse lavage during the operation, resulting in intramuscular and subfascial air. The following day, the medical team that accepted the patient from the on-call service had no knowledge of the use of pulse lavage and, when confronted with a confusing clinical picture and dramatic radiographs, proceeded with urgent surgical exploration. This case demonstrates an iatrogenic cause of intramuscular air and illustrates the importance of good communication between on-call and accepting services. In accordance with local Human Resources and Research Center (institutional review board) policies, the parents of the patient were informed that data concerning the case would be submitted for publication, and they consented. A ten-year-old boy presented with a history of decreasing ability to walk over a period of five days prior to presentation and fever of as much as 102° F (38.9° C). He was described as a previously healthy young man except for mild asthma, which was well-controlled with albuterol and Flovent (fluticasone propionate) inhalers. There was no history of trauma or injury. The examination was notable for an inability to bear weight on the right lower extremity, and the elicitation of pain with passive range of motion of the hip. There was no pain or swelling in the thigh, knee, or …

Measuring the Assessment and Counseling Provided with the Supply of Nonprescription Asthma Reliever Medication: A Simulated Patient Study

Over one quarter of asthma reliever medications are provided without prescription by community pharmacies in Australia. Evidence that community pharmacies provide these medications with sufficient patient assessment and medication counseling to ensure compliance with the government's Quality Use of Medicines principles is currently lacking. To assess current practice when asthma reliever medication is provided in the community pharmacy setting and to identify factors that correlate with assessment of asthma control. Researchers posing as patients visited a sample of Perth metropolitan community pharmacies in May 2007. During the visit, the simulated patient enacted a standardized scenario of someone with moderately controlled asthma who wished to purchase a salbutamol (albuterol) inhaler without prescription. Results of the encounter were recorded immediately after the visit. Regression analysis was performed, with medication use frequency (a marker of asthma control) as the dependent variable. One hundred sixty community pharmacies in the Perth metropolitan area were visited in May 2007. Pharmacists and/or pharmacy assistants provided some form of assessment in 84% of the visits. Counseling was provided to the simulated patients in 24% of the visits. Only 4 pharmacy staff members asked whether the simulated patient knew how to use the inhaler. Significant correlation was found between assessment and/or counseling of reliever use frequency and 3 independent variables: visit length (p < 0.001), number of assessment questions asked (p < 0.001), and the simulated patient who conducted the visit (p < 0.02). Both patient assessment and medication counseling were suboptimal compared with recommended practice when nonprescription asthma reliever medication was supplied in the community pharmacy setting. Pharmacy and pharmacist demographic variables do not appear to affect assessment of asthma control. This research indicates the need for substantial improvements in practice in order to provide reliever medication in line with Quality Use of Medication principles of ensuring safe and effective use of medication.

Levalbuterol versus albuterol

Albuterol has been used for more than 40 years to treat acute asthma exacerbations as a racemic mixture of isomers: the active form, (R)-albuterol, or levalbuterol, and (S)-albuterol, classically considered inert. The single-isomer formulation, levalbuterol, has been synthesized recently and used therapeutically when the racemate is deemed less desirable. Basic investigations indicate that racemic albuterol and levalbuterol can produce effects that favor asthma remediation, including corticosteroid amplification and reduction of inflammatory mediators; in contrast, (S)-albuterol produces opposite effects. With inhalation of racemic albuterol, circulating (S)-albuterol persists 12 times longer than levalbuterol, suggesting potential for paradoxical effects observed clinically. Although mainly consistent with basic findings, clinical studies suggest no overwhelming superiority of levalbuterol over racemic albuterol; however, levalbuterol's effects may be greatest in moderate to severe asthma patients, especially with racemic albuterol overuse. Recent adoption of the hydrofluoroalkane formulation has narrowed the cost gap between levalbuterol and racemic albuterol metered-dose inhalers, but it remains for the nebulized formulations. Thus, physician selection of these drugs has remained dependent on experience, pharmaceutical knowledge, and established prescribing habits combined with cost factors, formulary structures, and availability, such that racemic albuterol is still used significantly compared with levalbuterol to treat acute asthma exacerbations.

Respiratory safety pharmacology: Positive control drug responses in Sprague–Dawley rats, Beagle dogs and cynomolgus monkeys

Rats are most frequently used to fulfill ICH S7A requirements for respiratory safety pharmacology. We hypothesized that the models used to assess respiratory safety pharmacology present different ventilatory responses to bronchoconstriction, bronchodilation and respiratory depression. Respiratory monitoring was performed with head-out plethysmographs for rats, masks for dogs and bias airflow helmets for monkeys. Respiratory rate (RR), tidal volume (TV) and minute volume (MV) were recorded. Forty rats, 18 dogs and 8 monkeys were acclimated to the respiratory monitoring equipment. Animals received saline (IV), albuterol (inhalation), methacholine (IV) and remifentanil (IV). Albuterol increased TV in all species. Methacholine decreased TV and MV in monkeys. In dogs, methacholine increased TV, RR and MV. In rats, methacholine increased TV and decreased RR. Remifentanil induced central respiratory depression in all species with decreased MV, except in rats. Dogs presented a biphasic response to remifentanil with hypoventilation followed by delayed hyperventilation. The monkeys presented similar responses to humans which may be due to biologic similarities. Dogs and rats presented clinically significant ventilatory alterations following positive control drugs. Although, the response to bronchoconstriction in dogs and rats was different from humans, the two species presented ventilatory changes that highlight the potential adverse effect of test articles.

Clinical Scenario—An 18-Year-Old With Acute Dysphagia and Meat Impaction

A healthy 18-year-old male subject presented to the emergency department with acute dysphagia and odynophagia immediately after eating steak. He regurgitated several times, with no relief of his symptoms. His medical history was remarkable for asthma and seasonal and environmental allergies, for which he was treated with, as needed, albuterol inhaler and montelukast. He also had a remote episode of apparent anaphylaxis to shellfish requiring an emergency department visit. On examination he was seen in the emergency department in some distress, holding a cup into which he was periodically expectorating saliva.

Severe Asthma With Markedly Increased Asbestos of 2 Types &amp; TXB2, and Markedly Reduced Acetylcholine, DHEA &amp; Drug Uptake in Parts of Upper Lungs, &amp; Similar Abnormalities at Respiratory &amp; Cardiac Center of Medulla Oblongata: Complete Elimination of This Asthma within 15 Days Using One Optimal Dose of Astragalus &amp; Application of Strong Red Light &amp; EMF Neutralizer on Respiratory

When the window of an Asbestos-contaminated room from a broken ceiling was opened wide, A 73 year-old male physician of Oriental origin, who was sitting in the next room, suddenly developed a severe asthma attack, which did not stop by the use of a hand-held Albuterol inhaler. Temporary relief was obtained only by using a Compressor-Nebulizer (Inspiration 626 with Albuterol Sulfate Inhalation Solution 0.083%). During the attack, abnormal areas were discovered at the upper lobes of both lungs, where Thromboxane B2 (TXB2) was markedly increased to 500 ng (BDORT units) (the rest of the lung had about 2.5 ng), 2 types of Asbestos (Chrysotile and Crocidolite) were abnormally increased to 0.120-0.135 mg, (BDORT units) Acetylcholine was markedly reduced to 0.5 ng (the rest of the lung was low, about 100 ng), DHEA was extremely reduced to 1 ng (the rest of the lung had about 52 ng), and telomere was less than 1 yg (= 10(-24) g). Bacterial & viral infections were also present in these abnormal areas, but no antibiotics entered the abnormal parts of the lungs. Therefore, one optimal dose of Astragalus was given once, which resulted in a rapid continuous excretion of large amounts of the above 2 types of Asbestos & TXB2 in urine & sputum, and Asthma symptoms reduced slightly in severity. Additional acupuncture & shiatsu given on all the known acupuncture points for lung disease only created slight, temporary improvement. Then, the respiratory & cardiac center of the Medulla Oblongata was found to have similar abnormalities as the lungs. Therefore, 100 mW output of Light Emitting Diode of red spectra (650 nm center spectrum) was projected on the abnormal area of the medulla oblongata on the back of the head. This resulted drug uptake of on and off and significantly reduced difficulty of breathing. Additional application of the EMF Neutralizer on the abnormal area of the Medulla Oblongata for 3 hours resulted in continuous drug uptake and complete disappearance of asthma. As a result of one optimal dose of Astragalus, the remaining Asbestos in the lungs & medulla oblongata was completely excreted in the urine and Sputum in 2 weeks. Then, even when the patient entered the Asbestos-contaminated room and slept there every day without opening the window, no asthma attack occurred even as late as 5 months later.

Reflections of an Associate Teacher

Reflections of an Associate Teacher LA Harris (bio) It is with full clarity that I now appreciate the impact and trickle down effect that poverty has on parenting. See, I am a single mom of a wonderful nearly 7-year-old boy. And I do mean wonderful. Today, however, I punished him for not remembering to give his teacher a note. He has allergic asthma. He was to give the note that was tucked in a Ziploc baggie and wrapped around his albuterol inhaler to his teacher so that he could get his doses in today. We spoke about it at length in the car. He said he understood the importance of it and agreed that he could be responsible and manage this all-important task. Well . . . he forgot. It just so happened that today was a very difficult day for me to be at work. I am bored stiff at work almost daily and feel like I am wasting my talents watching a talented teacher teach whilst I police the carpet and shuffle children back and forth to the bathroom. I remember back in September the children would see me and instead of saying "Good Morning Ms. Harris," they would say, " I need to go to the bathroom." Some other daily tasks include wiping down the tables, making sure the marker caps are facing up (clearly an especially important chore because I was led over to the shelf and given a demonstration on how to make sure that this is done daily), sharpening pencils, changing calendar pieces (except when it is done for me – then I get paranoid . . . did I forget to do that one day? are they not straight enough? . . . oh well, one less tiny task to worry about I suppose) , sweeping the floor, and choosing and reading a book. Choosing a book is my single-most consistent chance to present something intellectual and of my own choosing to the group. Except sometimes there is a book pre-selected for me . . . then I wonder if my "intellectual" slot is only half mine. Oh and I can't forget my favorite: walking in the back of a line on Tuesdays behind 22 students carrying a heavy bin of library books whilst she leads from the front with a nice hot cup of coffee in her hand and one single sheet of paper. I am gently reminded, "Ms. Harris, could you get the book bin." My head says, "Yes, Ms. Daisy," and to steal a quote from one of our students, "I hate being in the back!" My usage of a 5-year-old student's tantrum-filled [End Page 69] verbiage ("I hate being in the back") would be strictly reserved for the days when I am gently reminded to grab the flimsy book bin filled with 22 assorted books that were checked out of the library the previous week and need to be returned for more. Each child selects his or her own book and carries it upstairs to the book bin but somehow the returning of the books becomes a huge burden for me to carry in silence with a smile. HOORAY! What a way to start my day after sitting in traffic on the Riverway and barely mothering my child each morning. My son forgot to hand in the note, perhaps because when he got there a substitute teacher was in his class. Maybe, just maybe, he took what I said literally. "Give this note to Ms. Mckay and know that Mama loves you." He replied, "OK, Mama, love you too," and boarded his shuttle bus. Well Ms. Mckay was out all day and he had a "sub." What's a first grader to do? Think? No. PLAY! They play even harder when their teacher is out, and that he did. So what? He went 10 hours without meds; he was wheezing this morning and a tiny bit when I picked him up at 5:30. Even with asthma being such a tricky disease, he won't tell the white women who care for him during the day that he can't breathe right anyways. He only tells me. I'm not certain why, but he...

Anticholinergic Esotropia

In this journal, Oh and Shin (1) recently described a patient who developed esotropia and mydriasis 7 days after beginning treatment with haloperidol and benztropine mesylate. They attributed the esotropia to convergence caused by the excessive accommodative effort required to overcome the anticholinergic effects of these medications. Another case of anticholinergic esotropia has just been reported in a 5-year-old girl taking oxybutynin (Ditropan) for enuresis (2). We recently examined a patient whose clinical history casts further light on this phenomenon. A 29-year-old woman presented with a 1-month history of horizontal diplopia. She had had esotropia in early childhood that gradually evolved into a consecutive exotropia. She also had a history of schizophrenia, depression, and anxiety and was being treated for these conditions with escitalopram (Lexapro), benztropine mesylate (Cogentin), quetiapine (Seroquel), aripiprazole (Abilify), hydroxyzine pamoate (Vistaril), cyclobenzaprine (Flexeril), and lamotrigine (Lamictal). She had asthma and used an albuterol inhaler. Ophthalmologic examination revealed a distance visual acuity of 20/30 in the right eye and 20/25 in the left eye. Pupils measured 6 mm bilaterally in dim illumination and reacted sluggishly to direct light, constricting only to 5 mm. Dynamic retinoscopy showed decreased accommodation bilaterally. Horizontal optokinetic testing showed asymmetrical monocular responses that were greater nasally than temporally, indicating ocular misalignment within the first year of life. Prism and alternate cover testing showed an esotropia of 20 prism-diopters when fixating on a distance target and 45 prism-diopters when fixating on a near target. Cycloplegic refraction showed no significant refractive error. She had no latent nystagmus, dissociated vertical deviation, or cross fixation. Extraocular movements were full with 1+ inferior oblique muscle overaction bilaterally. Anterior and posterior segment examinations were normal. We informed the patient that she would probably require strabismus surgery. However, we suspected that the anticholinergic medication might be contributing to the esotropia, especially benztropine mesylate, hydroxyzine pamoate, and cyclobenzaprine. We discussed the issue of overmedication with her psychiatrist, who elected to discontinue her quetiapine, lamotrigine, cyclobenzaprine, aripiprazole, and hydroxyzine pamoate. The dose of benztropine mesylate was reduced. On follow-up examination 2 months later, the patient reported that her diplopia had resolved. Dynamic retinoscopy showed improved accommodation. Prism and alternate cover testing now showed a constant exotropia of 12 prism-diopters when fixating at distance and 9 prism-diopters when fixating at near. Our patient's treatment with multiple psychotropic medications had converted her long-standing exotropia to an esotropia with associated diplopia. Reducing the anticholinergic medications allowed her eyes to revert to their baseline exotropic position and produced resolution of her diplopia. We agree with the pharmacological mechanism proposed by Oh and Shin (1) in which anticholinergic-induced paresis of accommodation leads to excessive accommodative effort with a corresponding excess of accommodative convergence. In children with accommodative esotropia, it is common to see a large-angle esotropia develop in the waiting room after administration of topical anticholinergic medications to dilate the pupils. Conversely, phospholine iodide, a cholinesterase inhibitor that enhances the effect of acetylcholine on the ciliary muscle, is used in topical form to eliminate small-angle esotropia (3). Given that so many widely used medications have anticholinergic properties, it is surprising that anticholinergic esotropia is not reported more regularly. Our patient's preexisting strabismus and absence of fusion rendered her susceptible to this complication. As Oh and Shin (1) noted, their patient may have also had several predisposing neurologic factors. The need for an intrinsic predisposition for anticholinergic esotropia would best explain the striking rarity of this complication. Since examining our patient and reading the similar report by Oh and Shin (1), we have begun routinely screening for anticholinergic medications in patients with esotropia before planning strabismus surgery. Jennifer M. Anderson, MD Department of Ophthalmology University of Arkansas Little Rock, Arkansas Michael C. Brodsky, MD Department of Ophthalmology Mayo Clinic Rochester, Minnesota [email protected]

Index of Suspicion

Index of Suspicion

Primary hyperaldosteronism in a domestic ferret with an adrenocortical adenoma

A 6-year-old spayed female domestic ferret was evaluated because of lethargy, alopecia, pruritus, and an abdominal mass. On initial examination, nonregenerative anemia, mild azotemia, and a large left adrenal gland mass were identified. However, deterioration of the ferret's general condition prevented excision of the mass, and dyspnea, weakness, hypertension, and severe hypokalemia developed. Plasma aldosterone concentration was >3329 pmol/L, confirming a provisional diagnosis of hyperaldosteronism. High concentrations of sex hormones were also observed, but baseline cortisol concentration was within reference limits. Medical treatment included oral administration of spironolactone, potassium gluconate, leuprolide acetate, amlodipine, and benazepril. Inhalation of albuterol proved effective in reducing the dyspnea. In the following weeks, serum potassium concentration returned to within reference limits and hypertension decreased, but dyspnea persisted. Two months after initial examination, the ferret became anorectic and was euthanized. Histologic examination revealed a large left adrenal gland adenoma, progressive chronic nephropathy, severe pulmonary edema, and focal fibrosis in the left ventricle. Immunohistochemical staining of the adrenal gland mass revealed aldosterone within neoplastic adrenocortical cells. Findings suggested that primary hyperaldosteronism should be considered as a possible cause in ferrets with hypokalemia, hypertension, and an adrenal gland mass. Early detection of aldosterone-secreting masses might allow for removal of the tumor before irreversible complications occur.

Final Count Down to HFA Albuterol Inhalers: Are We Ready as Yet?

Final Count Down to HFA Albuterol Inhalers: Are We Ready as Yet?

Approach to acute renal failure in biopsy proven myeloma cast nephropathy: Is there still a role for plasmapheresis?

A 75-year-old Caucasian man with hypertension and severe, emphysema, presented to the Veterans Administration New York Harbor Health Care System Hospital outpatient clinic, for his bi-yearly physical in March 2003. The patient had a macrocytic anemia and a serum creatinine (Scr) level of 3.3mg per 100 ml (baseline Scr, 0.9 mg per 100 ml 1 month earlier). An outpatient nephrology consultation was initiated after a comprehensive negative gastrointestinal workup. Detailed history and physical examination were performed. He denied the following symptoms: headache, visual changes, hesitancy, frequency, oliguria, dysuria, nausea, vomiting, fever, chills, bone pain, and change in weight, appetite or bowel habits. He also denied the following: hematochezia, melena, fatigue, dyspnea, dizziness, or chest pain. His medications on presentation included lisinopril 20 mg day -1 and combination albuterol and atrovent inhaler. He denied occupational or chemical exposure, and use of herbal or over-the-counter medications. The patient quit smoking and drinking over 20 years ago. He had no history of diabetes mellitus, macroscopic hematuria, or tuberculosis. His family history was non-contributory. Physical examination revealed an alert, healthy-appearing older male with a blood pressure of 134/83 mm Hg (without orthostasis), pulse rate of 78 beats min -1 , weight of 89kg, and body mass index of 29 kg m -2 . There was no lymphadenopathy. Heart examination showed regular rate and rhythm, without murmurs, rubs, or gallops. Lungs were clear to percussion and auscultation. Abdomen had normal bowel sounds, was soft, non-tender, with no masses or hepatomegaly. There was dullness in Traube's space on deep inspiration. Extremities revealed no clubbing, cyanosis, rash, or edema. Neurological examination was essentially normal. Diagnostic studies were performed. Renal ultrasound showed 11.7 and 12.4 cm right and left kidney, respectively. Both kidneys demonstrated mildly increased, diffuse parenchymal echogenicity, consistent with mild medical renal disease, with no scarring or masses. There was no hydronephrosis. Renal veins were patent bilaterally. The bladder was not distended. Spleen was enlarged, measuring 12.6 cm. Results of the laboratory studies are detailed in Table 1. Urinary dipstick showed trace protein but sulfosalicyclic acid testing was not performed. Twenty-four-hour urine protein level was 3.1 g day -1 . Urine protein electrophoresis was unremarkable, but urine and serum immunofixation electrophoresis and serum protein electrophoresis showed a monoclonal band (IgAκ). His quantitative serum immunoglobulin A (IgA) level was 2330 mg per 100ml. Bone marrow biopsy revealed 90% plasma cells (Figure 1). Skeletal survey was negative. A diagnosis of multiple myeloma (MM) Durie-Salmon stage III was made.

Diagnosis of Congenital Unicuspid Aortic Valve by 64-Slice Cardiac Computed Tomography

A 28-year-old man presented to our hospital with 3 days of intermittent, escalating dyspnea and chest tightness. He reported that he often experienced dyspnea when smoking, chewing tobacco, or exerting himself beyond the level of normal daily activity. His discomfort was partially relieved by his albuterol inhaler, which he used ≥10 times per day. As a child, he was told that he had a precordial murmur, but he had not sought medical attention. Five years prior to this evaluation, he was having similar symptoms and was treated with antibiotics. He was told at that time that he had mild asthma. On examination, the patient was mildly dyspneic, with a harsh systolic murmur at the right upper sternal border. Transthoracic echocardiogram revealed left ventricular thickening with normal systolic and diastolic function and a left ventricular ejection fraction of 65%. A peak gradient of >4 meters per second was noted, with a calculated aortic valve area of <0.9 cm2. The morphology of the valve was not clearly seen, but a unicuspid valve was suspected. Transesophageal echocardiogram demonstrated a heavily calcified unicuspid aortic valve with reduced cuspid excursion and moderate to severe aortic regurgitation (Figure ​(Figure1a1a). Preoperative 64-slice computed tomographic coronary angiography (Lightspeed VCT, GE Healthcare) confirmed the valve morphology and demonstrated no significant coronary narrowing (Figure ​(Figure1b1b). Figure Unicuspid aortic valve evaluated with (a) transesophageal echocardiography, (b) computed tomography, and (c) gross pathology. At operation, the valve was found to be unicuspid with one true unfused commissure. The free edge traversed the cusps without contact with the aortic wall (Figure ​(Figure1c1c). The patient received a St. Jude medical mechanical prosthesis, and his postoperative course was uncomplicated. The estimated incidence of unicuspid aortic valve is 0.02% (1–3). During development, the aortic valve is formed from three tubercles, which each develop a cusp and sinus of Valsalva. Fusion of the cusps results in a unicuspid valve. Unicommissural unicuspid valves, as in our case, have one lateral attachment and an eccentric orifice. Acommissural unicuspid valves have no lateral attachment to the aorta.

Formoterol fumarate inhalation powder vs albuterol nebulizer for the treatment of asthma in the acute care setting

Although albuterol remains the standard treatment for asthma in the emergency department, formoterol fumarate may be more advantageous, with its rapid and long-lasting bronchodilation. To compare formoterol fumarate with albuterol in controlling acute asthma exacerbation. Patients aged 18 to 65 years who presented to the emergency department with mild to moderate asthma exacerbation (peak expiratory flow rate [PEFR], 40%-60% of predicted) were randomized to receive either formoterol fumarate aerolizer (12 microg) or albuterol nebulizer (2.5 mg) every 30 minutes up to 2 treatments. Symptom scores and PEFRs were measured at each treatment. Thirty-four patients (19 in the albuterol arm and 15 in the formoterol fumarate arm) were enrolled. At 30 and 60 minutes, the mean PEFR of the albuterol group increased from 43.7% of predicted to 51.9% of predicted and 54.6% of predicted, respectively, and the formoterol fumarate group had changes in the mean PEFR from 49.3% of predicted to 55.5% of predicted and 57.3% of predicted, respectively, and the mean change in the 2 groups was not significantly different at 30 and 60 minutes (P = .64 and .57, respectively, by t test). The albuterol group improved in symptom scores by 3.7 and 5.5 from 0 minutes to 30 and 60 minutes, respectively, and in the formoterol fumarate group these values were 3.1 and 4.9 at 30 and 60 minutes, respectively, and the mean change in the 2 groups was not significantly different at 30 and 60 minutes (P = .61 and .76, respectively, by t test). Formoterol fumarate is as effective as albuterol inhalation for the treatment of adults with mild to moderate asthma exacerbations in the acute care setting.