May 2009 VOL 17 NO 1 Chronic Cough ... Page 01 Breast Cancer ... Page 04 Viral Gartroenteritis ... Page 11 Dyslexia ... Page 15 SQUARE in International Business ... Page 20 Managing Editor Omar Akramur Rab MBBS, FCGP, FIAGP PG Dip. Business Management (India) Associate Editor Editorial Md. Mahfuzur Rahman Sikder MBBS Dear Doctor: Welcome to this edition of "the SQUARE " healthcare bulletin! Members of the Editorial Board We hope you've been enjoying this publication very much! Muhammadul Haque This issue of "the SQUARE " features a variety of articles including “chronic cough”, is the MBA most common presenting symptom in adults who seek medical treatment in an ambulatory A. H. Mahbub Alam setting. The management of chronic cough presents a challenge for the clinician. We also M Pharm, PhD bring you all the details on “viral gastroenterology”, a leading cause of severe diarrhea in both adults and children. We have also focused on “breast cancer”, the second most common type of cancer in women. In addition, we highlighted on “Dyslexia”, a learning Special Contribution disability that can hinder a person's ability to read, write, spell, and sometimes speak. Kazi Shamim Al Mamun Besides, our regular feature comprises "SQUARE in International Business" as well. MBBS Md Muhitul Matin We believe you will enjoy reading this publication and that the contents provided will prove MBBS helpful towards your goal of optimum health! Finally, on behalf of the management of SQUARE, we wish you an ecstatic, healthy and prosperous life. Acknowledgement Product Management Department International Marketing Department Thank you! Information Assistance Md. Masudul Alam MA Omar Akramur Rab ISSN 1681-5552 Key title: The square (Dhaka) www.squarepharma.com.bd/MedicalPeriodicals.html Abbreviated key title: Square (Dhaka) The views expressed in this publication do not necessarily reflect those of its editor or SQUARE Pharmaceuticals Ltd. Information in “the SQUARE” may be reprinted or translated to other languages without permission but proper credit must be given to “the SQUARE”. VOL 17 NO 1 May 2009 Chronic Cough Cough is an important physiologic mechanism that defends immunocompetent, nonsmoking patients with normal chest against respiratory pathogens and helps clear the tracheo- radiograph findings. In order of frequency, they are as follows: bronchial tree of mucus, foreign particles and noxious aero-sols. 1. Upper airway cough syndrome (UACS), previously Excessive cough is one of the most common symptoms for which referred to as postnasal drip syndrome (PNDS) patients seek medical care and may represent up to one-third of a 2. Asthma pulmonologist's outpatient practice referrals. Estimating the 3. Gastroesophageal reflux disease (GERD) duration of cough is the first step in narrowing the list of possible These 3 conditions make up what is called the “pathogenic diagnoses. There is controversy about how best to define chronic triad of chronic cough.” cough. According to the current study, chronic cough affects A fourth etiology that deserves mention is nonasthmatic 10% to 20% of adults and is defined as lasting longer than 8 eosinophilic bronchitis (NAEB), which is relatively common, weeks in adults and longer than 4 weeks in children. easy to diagnose and treat and should be considered early on The Pathophysiology of Cough in the diagnostic evaluation. The pathophysiology of cough is incompletely understood. Focusing on the diagnosing and treating these conditions is Cough is commonly triggered by mechanical or chemical extremely successful at treating chronic cough. stimulation of receptors in the pharynx, larynx, trachea and Upper airway cough syndrome bronchi. Cough receptors also exist in the nose, paranasal sinuses, external auditory ear canals, tympanic membranes, Postnasal drip syndrome refers to the sensation of secretions parietal pleura, esophagus, stomach, pericardium and from the nose or sinuses that drain into the pharynx in diaphragm. addition to nasal discharge and frequent throat clearing. Unfortunately, this is largely based on patients’ subjective Signs and Symptoms of Chronic Cough symptoms, which frequently do not show any significant Although the signs of a cough are self-explanatory, what physical examination findings. In fact, 20% of patients with differentiates the cause of a cough are the associated signs and PNDS-induced cough are unaware of the presence of symptoms. The signs and symptoms of the chronic cough postnasal drip or its link to their cough. Even the presence of can be hard to assess, because many causes of the chronic mucus in the oropharynx or cobblestoning of the cough have overlapping signs and symptoms. oropharyngeal mucosa only suggest this as a cause. These findings are sensitive but not specific. A chronic cough can occur with other signs and symptoms, which may include: PNDS has been broadened to UACS, referring to a myriad ❏ A runny or stuffy nose of rhinosinus conditions that are related to cough. A nasal ❏ A sensation of liquid running down the back of the throat discharge, frequent need to clear the throat and mucoid or ❏ Wheezing and shortness of breath mucopurulent secretions in the posterior pharynx suggest an ❏ Heartburn or a sour taste in the mouth upper airway cough syndrome. Sinus imaging may be ❏ In rare cases, coughing up blood diagnostic of acute or chronic sinusitis. Causes of Chronic Cough UACS includes the following: ❏ ❏ The etiologies of chronic cough are PNDS Rhinitis due to anatomic ❏ numerous and may include Allergic rhinitis abnormalities ❏ ❏ pathology from the nose and Vasomotor rhinitis Rhinitis due to physical ❏ nasopharynx to the distal bronchial Nonallergic rhinitis with or chemical irritants ❏ tree. Obvious causes of chronic eosinophilia (NARES) Occupational rhinitis ❏ ❏ cough such as low--grade chronic Postinfectious rhinitis Rhinitis medicamentosa ❏ ❏ bronchitis secondary to exposure to tobacco smoke and Bacterial sinusitis Rhinitis of pregnancy ❏ angiotensin-converting enzyme (ACE) inhibitor use can be Allergic fungal sinusitis easily ascertained though the history. After this, the challenge for UACS is considered the most common cause of chronic the clinician lies in how to efficiently and systematically evaluate cough and has been implicated as the cause in up to 87% of the patient without an overly exhaustive workup. Further patients. compounding this is the fact that oftentimes more than one Although oftentimes a causative etiology for the rhinitis condition is simultaneously present. might be suggested from the patient’s history and Prospective studies have shown that 3 conditions account for symptomatology, the hallmark of UACS is that this the etiologic cause of chronic cough in 92-100% of syndrome has no pathognomonic findings and the diagnosis the SQUARE healthcare bulletin 1 Chronic Cough VOL 17 NO 1 May 2009 is made on the basis of response to specific therapy, which The evaluation of chronic cough in children is similar to the includes antihistamines and decongestants. evaluation in immunocompetent adults. However, in younger children, the adenosine 5'-monophosphate bronchial challenge Asthma has been shown to be more specific than the methacholine The hallmarks of asthma are variable airflow obstruction and challenge (87 percent versus 57 percent) in differentiating airway hyperresponsiveness, which manifest as shortness of asthma from other chronic pulmonary diseases of childhood. breath, wheezing, dyspnea and cough. Cough occurs in all In children, asthmatic symptoms may be caused by GERD asthmatics and in a subset of patients with cough-variant (prevalence ranging from 34 percent to 89 percent). Some asthma (CVA), it is the only presenting symptom. evidence suggests that treatment of GERD with antireflux Gastroesophageal reflux disease medications may reduce the symptoms of asthma, leading to a reduction in asthma medication requirements. The following 2 mechanisms have been postulated for GERD-associated cough: Sinusitis, tuberculosis, pertussis and cystic fibrosis are other ❏ Distal esophageal acid exposure that stimulates an causes of chronic cough that should be considered in esophageal-tracheobronchial cough reflex via the vagus nerve children. Foreign body aspiration is a possibility in young ❏ Microaspiration of esophageal contents into the children who have chronic cough. Recurrent infections may laryngopharynx and tracheobronchial tree indicate an immunologic disorder as the cause of cough. The second cause is called laryngopharyngeal reflux (LPR) or Finally, chronic cough in children can be caused by several extraesophageal or silent GERD, and it differs from congenital abnormalities and disorders, including vascular traditional GERD in that it does not manifest as heartburn rings, tracheoesophageal fistulas and primary ciliary and tends to occur when the patient is upright as opposed to dyskinesia. However, these conditions are rare. lying flat. This silent GERD can be present in as many as Workup and Management 75% of patients with chronic cough. Symptoms of LPR An anatomic and diagnostic approach has been recommended include throat clearing, hoarseness and globus sensation. as a framework for workup of chronic cough with Nonasthmatic eosinophilic bronchitis demonstrated success in treatment in up to 98% of patients. Nonasthmatic eosinophilic bronchitis has been implicated as Every patient with chronic cough needs a thorough history an etiology of chronic cough in 13-33% of patients. It is taken and physical examination performed as