The natural history of right bundle branch block (RBBB) has been studied primarily from the perspective of its prognostic importance in patients with organic heart disease. The limited number of studies that included primarily persons without heart disease were mainly conducted before attention was focused on the potential importance of deviations in the mean frontal plane QRS vector (A QRS) as a possible indicator of impaired conduction in the left bundle branch system. Marked left axis deviation may be due to impaired conduction in the anterosuperior part of the left bundle branch, and marked right axis deviation to impaired conduction in the posteroinferior part of the left bundle branch system. These deviations in A QRS in conjunction with complete RBBB suggest impaired conduction in both the right and left bundle branch system.
Observations about Fibronectin and Procollagen 3 Levels in Bronchoalveolar Lavage of Asbestos-Exposed Human Subjects and Sheep
The present report extends earlier investigations on mechanisms of pulmonary injury associated with the presence of respirable particles in the bronchoalveolar milieu. In the animal model, this study documents that asbestos-associated alveolitis which progresses to peribronchiolar and endobronchiolar fibrosis (the fundamental lesion of asbestosis) is associated with significant early increase in the level of procollagen 3 in bronchoalveolar lavage fluid and a sustained increase in the fibronectin level, which do not occur in the nonfibrosing and regressive latex-associated alveolitis. In asbestos workers with clinical and lavage evidences of alveolitis, levels of procollagen 3 and fibronectin are similarly increased in bronchoalveolar lavage fluid, which should improve our understanding of disease activity in asbestos workers.
In the sheep tracheal lobe, this study documents that after a single high-dose exposure to asbestos, there are severe derangements of the bronchoalveolar milieu and activation of a chronic sustained alveolar, peribronchiolar and endobronchiolar inflammatory process which evolves to fibrosis. On bronchoalveolar lavage the increased macrophage and neutrophil cellularity is associated with increased fibronectin, a glycoprotein produced locally by the macrophage, known to be chemotactic and an attachment factor for fibroblasts and a stimulant for fibroblast replication in association with another macrophage-derived fibroblast growth factor (MDFGF). In the asbestos-associated alveolitis in sheep, we have reported enhanced production of MDFGF and macrophage-derived neutrophil chemotactic factor (MDNCF). Because these three macrophage-derived factors (fibronectin, MDFGF, and MDNCF) are currently thought to have major roles in the pathogenesis of pulmonary fibrosis, our data from sheep suggest that these factors contribute to maintain the alveolitis on a long-term basis and lead to its progression to asbestosis. The mechanisms which activate the macrophage to produce these factors are likely related to the prolonged retention of asbestos fibers in the bronchoalveolar milieu, as suggested by our previous study of alveolar clearance of chrysotile in the sheep model. In the model, we have shown that one year after cessation of exposure, 11 percent of the fibers shorter than 8μ, 32 percent of the fibers with length in the range of 8μ to 20μ, and 50 percent of the fibers longer than 20|i were still recoverable by pulmonary lavage. The persistence of these fibers in the bronchoalveolar milieu may constitute the determinant factor for maintenance of activated macrophages and alveolitis due to the concern of My Canadian Pharmacy.
The present study confirms previous data on the effect of muscle mass on mortality in patients with COPD. In stable patients, MD is associated to an increased risk of death. In addition, as a remarkable finding, we show that the prognostic influence of muscle mass can be assessed by determining the MAMA, an inexpensive, simple, and rapidly obtained anthropometric measure. MAMA < p25 was found to be a poor prognosis marker, exerting an influence in our series superior to that of other anthropometric parameters such as BMI or FFMi. In underweight patients, the presence of muscle depletion did not contribute significant prognostic information. However, those subjects with normal body weight or overweight status who presented MAMA < p25 had a poorer prognosis.
A total of 114 patients with a diagnosis of COPD were studied. Of these, 18 patients (15.8%) were excluded for different reasons: 7 patients (6.1%) with decompensated cor pulmonale, 3 patients (2.6%) with liver cirrhosis, 2 patients (1.7%) with neoplasms, 2 patients (1.7%) due to sustained oral corticosteroid use, 2 patients (1.7%) because of heart failure, 1 patient (0.9%) with chronic renal failure, and another patient (0.9%) due to malabsorption syndrome. A total of 96 patients were therefore finally included (all male; mean age, 69 ± 9 years [± SD]). Table 1 shows the baseline characteristics of these patients.
Investigation about Mid-Arm Muscle Area Is a Better Predictor of Mortality Than Body Mass Index in COPD
A prospective study was made of a cohort of 114 patients with stable COPD. The patients were recruited in the last trimester of the year 2000, with a subsequent follow-up period of 3 years. The diagnosis of COPD was based on a current or previous smoking history (> 20 packs-year), clinical assessment, and pulmonary function testing. The postbronchodilator FEV1, expressed as a percentage of the theoretical value, was used to classify the patients according to Global Initiative for Chronic Obstructive Lung Disease (GOLD) committee criteria. Patients exhibiting > 15% reversibility in the bronchodilator test were according to the latest excluded from the study, as were those subjects with a previous diagnosis of bronchial asthma, bronchiectasis, cystic fibrosis, upper airways obstruction, or bronchiolitis related to systemic disorders. Patients with concomitant diseases capable of altering nutritional status (heart failure, liver cirrhosis, decompensated diabetes, chronic renal failure, uncontrolled thyroid pathology, neoplasms, decompensated chronic cor pulmonale, sustained systemic steroid use) were also excluded. The patients were required to be in a stable phase of COPD, defined as the absence of disease exacerbations in the 2 months preceding the study held due to My Canadian Pharmacy.
My Canadian Pharmacy: Mid-Arm Muscle Area Is a Better Predictor of Mortality Than Body Mass Index in COPD
Alow body mass index (BMI) has been shown to be an independent indicator of poor prognosis in patients with COPD. This observation has renewed interest in the study of the nutritional aspects of COPD. In this context, a new severity classification has recently been proposed: the BODE index—(BMI, airflow obstruction, dyspnea, and exercise capacity)—which in addition to BMI considers the degree of bronchial obstruction, dyspnea, and exercise tolerance. This classification, proposed by Celli et al, stresses the multicomponent nature of COPD and addresses not only its pulmonary consequences but also the systemic manifestations of the disease. Among the latter, the authors point to the need to conduct an adequate nutritional study. However, the assessment of nutritional status based on body weight (or BMI) has limitations, since it affords no qualitative information on body composition, which is also altered in these patients.