生物制剂治疗所致乙型肝炎病毒再激活研究进展

目的 随着生物制剂在临床逐步广泛的应用,由此导致的乙型肝炎病毒(HBV)再激活越来越受关注。HBV再激活的患者可发生肝衰竭,甚至导致死亡。对有HBV再激活发生风险的人群进行筛查、预防性抗病毒治疗和监测,已经成为各大指南的共识。本文就在应用生物制剂治疗过程中HBV再激活的发生风险分层、发生机制和预防性抗病毒治疗药物应用等作一综述。     

免疫抑制剂致乙肝病毒再激活的临床分析

目的 探讨需要使用免疫抑制剂的乙肝病毒（HBV）感染者使用免疫抑制剂后乙肝病毒再激活的发生及其抗病毒治疗的收益.方法 收集我院近3年收治的46例使用免疫抑制剂患者的临床资料,并分析其免疫抑制剂类型、肝脏损害程度及抗病毒治疗情况.结果 出现乙肝再激活17例（37.0%）,发生重症肝炎6例（13.0%）.接受拉米夫定预防性抗病毒治疗的患者有80%HBV DNA下降,乙肝再激活后再行抗病毒治疗的7例患者中,2例死于肝衰竭.未作抗病毒治疗的患者中有10例（47.6%）乙肝病毒再激活.结论 所有需要使用免疫抑制剂的患者在用药前需要进行常规的HBV筛查,对存在HBV感染的患者需要考虑到HBV再激活.使用强烈的免疫抑制剂、糖皮质激素以及低龄、男性患者容易发生乙肝再激活.对具有高危因素的患者需要及时使用抗病毒药物,抗病毒药物的使用可以降低病毒再激活的风险.     

肿瘤患者化疗后乙型肝炎病毒再激活病例临床分析

目的观察肿瘤合并慢性HBV携带者化疗后HBV再激活抗病毒治疗的效果及化疗前预防性抗病毒用药对HBV再激活的预防作用。方法采用回顾性分析将13例肿瘤合并慢性HBV携带者分成两组：治疗性用药组8例，为化疗后HBV再激活致肝功能异常者，均停用原有化疗药物，给予拉米夫定100mg／d及保肝药治疗。预防性用药组5例，化疗前即予以拉米夫定100mg／d治疗，待血清HBV DNA水平降至〈10^3拷贝／ml之后再行化疗。随访两组患者的肝功能、HBV DNA水平及预后。结果8例化疗后HBV再激活者，出现肝功能异常后才给予拉米夫定抗病毒治疗，5例因肝功能衰竭而死亡，3例经抗病毒治疗后肝功能恢复，但推迟甚至终止了化疗。5例在化疗前接受预防性抗病毒治疗的患者中未观察到HBV再激活现象，无死亡病例。结论对于需要化疗的HBV携带者，预防比治疗更有意义。     

弥漫性大B细胞淋巴瘤患者化疗后乙型肝炎病毒激活情况分析

目的：比较弥漫性大 B细胞淋巴瘤（diffuse large B cell lymphoma,DLBCL）患者接受CHOP方案的基础上联合与不联合利妥昔单抗治疗后,HBsAg 阳性患者和 HBsAg 阴性患者的临床特点,HBV 激活的发生情况、转归及预防性抗病毒治疗的价值。方法回顾性调查在我院接受CHOP或R-CHOP方案化疗的DLBCL患者的临床资料,对比分析患者的临床特征及HBV激活情况。结果121名患者符合入选标准,其中24例为HBsAg阳性,97例为HBsAg阴性。7例患者化疗前病毒拷贝数＞103拷贝/mL,给予抗病毒治疗,无一例发生 HBV 激活;17例未接受预防性抗病毒治疗的 HBsAg阳性患者中,CHOP方案组1例（10％）发生 HBV 激活,R- CHOP 方案组4例（28．6％）发生 HBV激活,其中2例（14．3％）死于肝功能衰竭。RCHOP组 HBV激活的发生率明显高于CHOP方案组（P＝0．015）,两组均高于接受抗病毒治疗者（P＝0．018）。97例 HBsAg阴性患者中,只有1例同时伴有乙型肝炎核心抗体 HBcAb 阳性的患者发生 HBV激活,其发生率明显低于 HBsAg阳性患者（P＝0．000）。结论 HBsAg阳性患者接受CHOP,尤其是含有利妥昔单抗的方案化疗后,HBV激活风险不仅明显增高,而且对患者有严重危害,对于这部分患者给予预防性抗病毒治疗可以降低HBV激活风险,改善患者预后。既往感染过HBV的 HBsAg阴性患者在接受含利妥昔单抗的方案化疗后,亦可发生 HBV激活,但激活的风险较低,尚需进一步研究预防性抗病毒治疗在这部分患者中的价值。     

HBsAg阳性非霍奇金淋巴瘤患者抗HBV治疗期间HBV再激活的危险因素分析

目的:探讨HBsAg阳性非霍奇金淋巴瘤患者抗病毒治疗期间HBV再激活的危险因素,从而早期识别高危人群,指导临床治疗。方法:采用临床回顾性研究的方法,选择2011年10月至2018年3月期间在武汉大学中南医院住院治疗的90例HBsAg阳性非霍奇金淋巴瘤患者为研究对象,根据是否接受抗病毒治疗分为治疗组58例(抗病毒治疗)及对照组32例(无抗病毒治疗),观察两组患者的一般情况及实验室检查结果,比较两组患者化疗后HBV再激活、化疗延迟及肝功能损害的情况,分析HBsAg阳性非霍奇金淋巴瘤患者抗病毒治疗期间HBV再激活的危险因素。结果:两组患者平均年龄分别为(55.2±10.7)岁和(47.4±12.8)岁,差异有统计学意义(P<0.05)。治疗组患者发生HBV再激活10例(17.2%),较对照组HBV再激活12例(37.5%)显著减少,差异有统计学意义(P<0.05);两组患者化疗延迟率分别为24.1%、46.9%,差异有统计学意义(P<0.05);肝功能损害发生率分别为56.9%、40.6%,差异无统计学意义(P>0.05)。危险因素单因素分析结果显示年龄、化疗前血清HBeAg阳性、抗病毒药物种类、停用抗病毒药物及化疗周期方面,差异具有统计学意义(P<0.05)。多因素分析结果显示化疗前HBeAg阳性[OR=1.6,95%可信区间(CI):1.5~3.5],停用抗病毒药物[OR=15.5,95%可信区间(CI):1.5~171.9],化疗周期≥5[OR=3.0,95%可信区间(CI):1.2~7.7]。结论:预防性应用核苷(酸)类似物抗病毒药物能显著降低HBsAg阳性非霍奇金淋巴瘤患者化疗后HBV再激活率及化疗延迟率。化疗前血清HBeAg阳性、停用抗病毒药物及化疗周期≥5是HBsAg阳性非霍奇金淋巴瘤患者抗病毒治疗期间发生HBV再激活的独立危险因素。     

原发性肝癌局部化疗后肝炎及乙型肝炎抗病毒治疗的临床研究

目的分析肝癌化疗后肝炎发生的病因,探讨核苷类似物抗病毒治疗对化疗后乙肝病毒再激活肝炎疗效。方法收集明确诊断乙型肝炎后肝细胞癌患者120例,男108例,女12例,年龄28~85岁,平均（53.88±12.16）岁。肝癌患者均接受1次经导管肝动脉化疗栓塞（TACE）治疗;并分为抗病毒治疗组35例;未行抗病毒治疗组85例。抗病毒组中TACE前2周23例服拉米夫定;12例服阿德福韦酯,维持抗病毒治疗TACE后4周为观察终点。随访4周后,监测2组患者TACE前后肝功能及HBV载量水平变化和肝炎发生情况,观察核苷类似物抗病毒治疗HBV再激活肝炎的疗效。结果肝细胞癌患者化疗后HBV再激活33例,化疗后未再激活87例,HBV再激活发生率为27.50%。HBV再激活肝炎23例,发生率为69.70%;化疗药物性肝炎11例,发生率为12.64%,2种肝炎的发生之间差异有统计学意义（P=0.00）。抗病毒治疗组与未抗病毒组之间HBV再激活肝炎的发生差异有统计学意义（2χ=5.78,P〈0.05）,2组间药物性肝炎的发生差异无统计学意义。结论肝细胞癌化疗后发生HBV再激活肝炎和化疗药物性肝炎;HBV再激活肝炎的发生较化疗药物性肝炎多。核苷类似物（拉米夫定/阿德福韦酯）抗病毒治疗可明显降低肝细胞癌患者化疗后HBV再激活肝炎的发生。     

HBV再激活相关肝衰竭的研究进展

HBV感染是全球重大公共问题。当前的抗病毒治疗药物能够有效的控制病毒复制,但无法清除HBV,在停用了抗HBV药物之后病毒仍然有再激活的可能。实验研究及临床研究表明在感染HBV以后,虽然95%的成人能够自发达到临床痊愈,但病毒基因组仍在宿主的肝细胞内持续存在,当使用免疫抑制剂或肿瘤化疗等药物治疗实体和血液系统恶性肿瘤、风湿免疫疾病、HCV感染等基础疾病时,HBV复制可能重新激活。HBV再激活可能导致严重的临床结局,部分患者可出现肝衰竭,甚至死亡。我国的回顾性研究表明有9%~30%乙型肝炎相关慢加急性肝衰竭是由HBV再激活引起。因此,识别HBV再激活的风险人群并制订合理的预防措施对于减少乙型肝炎相关慢加急肝衰竭的发生有着非常重要的意义。简述了HBV再激活的定义、发生基础,同时论述了HBV再激活引起肝衰竭的诱因及机理,最后总结了需预防人群及措施。     

HBsAg阳性恶性肿瘤患者化疗后肝损伤及HBV再激活的临床分析

目的探讨HBsAg阳性肿瘤患者化疗后肝损伤情况及HBV再激活的相关危险因素。方法收集2011年1月-2013年12月在汕头市中心医院接受化疗的HBsAg阳性的恶性肿瘤患者共150例。其中43例行预防性抗病毒治疗,即化疗前、化疗期间和化疗结束后半年使用抗病毒治疗(试验组),107例未行预防性抗病毒治疗(对照组)。回顾性分析2组患者化疗后肝损伤情况。计数资料组间比较采用χ2检验,使用Logistic回归分析法分析影响化疗后HBV再激活的相关因素。结果所有患者经过化疗,63例(42.0%)出现肝损伤,其中肝脏不良反应分级:Ⅰ度13例(8.7%)、Ⅱ度29例(19.3%)、Ⅲ度15例(10.0%)、Ⅳ度6例(4.0%),2组肝损伤程度差异具有统计学意义(χ2=19.498,P=0.001)。试验组肝损伤发生率为18.6%(8例),比对照组51.4%(55例)明显降低,差异有统计学意义(χ2=25.864,P0.001)。Logistic单因素回归分析显示,化疗前乙型肝炎六项状态、HBV定量、是否使用激素及是否预防性使用抗病毒治疗差异具有统计学意义,将其纳入Logistic多因素回归分析显示,这4项指标均是患者化疗后HBV再激活的独立影响因素,其中预防性抗病毒治疗是患者化疗后HBV再激活唯一保护性因素。结论 HBsAg阳性肿瘤患者化疗后肝损伤发生率较高,预防性使用抗病毒治疗可以有效降低HBV再激活的发生率,从而减少肝损伤的发生。     

直接抗病毒药物时代HBV/HCV重叠感染的治疗

亚太地区,尤其是我国,为HBV感染高发地区,自2011年口服直接抗病毒药物(DAA)问世以来,抗HCV的治疗逐渐从IFN为基础的方案转向全口服药物方案。进入DAA抗HCV治疗的时代后,陆续观察到HBV再激活的发生,相比IFN治疗时期,HBV再激活发生得更早、更严重,甚至有HBV再激活相关的死亡病例及肝移植病例的报道。因此,全世界各大肝病学会都高度重视DAA时代HBV再激活的发生,此类药物的说明书也新增了黑框药物用药安全警示,警示患者在接受DAA抗HCV治疗前,必须筛查HBV感染标志物,并在开始DAA抗HCV治疗前、治疗中及治疗后,密切检测HBV再激活的发生,并且在必要时,及时开始启动抗HBV治疗。     

糖皮质激素致乙型肝炎病毒再激活死亡1例报道

我国是乙型肝炎病毒(HBV)感染高流行区,HBV感染者在接受免疫抑制剂或细胞毒性药物治疗期间或之后,可能出现不同程度的HBV再激活,死亡率较高。预防性应用拉米夫定等抗乙肝病毒药物可有效降低HBV再激活发生率和死亡率。本文报道1例糖皮质激素治疗致HBV再激活死亡的病例,并结合文献复习,探讨并提高对HBV再激活的发生率、危险因素、诊断及治疗等的认识。     

Diagnostic value of matrix metalloproteinases-1, −3 and −13 in patients with primary knee osteoarthritis: Relation to radiological severity

BackgroundKnee osteoarthritis (KOA) is an important cause of disability in elderly. Aim of the work: to study the expression of matrix metalloproteinases (MMP-1, MMP-3 and MMP-13) in serum of patients with KOA and relation to radiological findings.Patients and methodsOne hundred patients with KOA and 80 matching control were studied. The Kellegren Lawrence (KL) scale was assessed. The mRNA and protein expressions of MMP-1, MMP-3 and MMP-13 were assessed by “quantitative real-time polymerase chain reaction (qRT-PCR)” and western blotting, respectively.ResultsThere was a significant increase in the mRNA expression of MMP-1, MMP-3 and MMP-13 in patients (18.5 ± 3.4, 3 ± 0.5 and 2 ± 0.2, respectively) compared to controls (2.6 ± 0.4, 0.7 ± 0.3 and 0.3 ± 0.06, respectively)(all p < 0.001) and in the protein expression of MMP-1, MMP-3 and MMP-13 in patients (2.89 ± 0.01, 2.37 ± 0.07, 2.56 ± 0.02, respectively) relative to controls (1.15 ± 0.04, 0.79 ± 0.01, 1.02 ± 0.08 respectively (all p < 0.001). A significant correlation was found between the age of patients and mRNA expression of MMP-1 (r = 0.19, p = 0.01) and MMP-3 (r = 0.17, p = 0.019) and between the BMI and mRNA expression of MMP-1 (r = 0.16, p = 0.028). No significant correlation was found between mRNA expression of MMP-1, MMP-3 and MMP-13 and grade of KOA. At cut off values 5.5, 1.7 and 0.8, MMP-1, MMP-3 and MMP-13 could diagnose KOA at a sensitivity of 98 %, 100 % and 100 % respectively with 100 % specificity for all.ConclusionThe expression of MMP-1, MMP-3 and MMP-13 could be a valuable non-invasive marker for early diagnosis of primary KOA with no relation to radiological finding.     

A More Than <Emphasis Type="Italic">One-Hundred-Fold Higher</Emphasis> per Capita Rate of Authorship of Five Democratic Nations Versus Their Relatively Undemocratic Neighboring Nations Among 6,437 Articles in 14 Medical Journals: Does Democracy and Civil Liberties Promote Intellectual Creativity and Medical Research?

The aim of this work is to compare medical research productivity between democratic countries and their relatively undemocratic neighbors to identify mechanisms to promote medical research. Country of authorship was determined manually for articles published in 14 medical journals in 2005, and compared pairwise for democracies vs. relatively undemocratic nations: Israel vs. the rest of the Middle East; Japan vs. Russia; South Korea vs. North Korea; and Taiwan or Hong Kong vs. Mainland China. Democracies were quantitatively defined according to the Freedom House Index and the Economist’s Index of Democracy. The frequency of publication of Israeli authors of unsolicited articles (excludes editorials) was found to be 1.08%, while its percentage of the world population is only .11% (OR = 9.97, 95%–ORCI: 4.30–23.1, P < 0.0001). This increase was invariant for more prestigious original articles (investigations) vs. less prestigious review articles or case reports, and for more prestigious high-impact factor journals vs. less prestigious low-impact factor journals. This increase was apparently not due to political favoritism: the relative frequency (RF) of Israeli authors of unsolicited articles was significantly higher than the RF of Israeli authors of solicited articles (i.e., invited editorials) (1.08% vs. 0.13%, OR = 8.38, 95%–ORCI = 1.46–48.1, P = 0.007); and was significantly higher than the RF of Israeli editorial board members (1.08% vs. 0.08%, OR = 13.0, 95%–ORCI = 2.27–74.7, P < 0.0001). Contrariwise, the frequency of publication of authors from the Middle East excluding Israel was 0.30%, while its percentage of the world population is 4.04% (OR = 0.071, 95%–ORCI = 0.04–0.12, P < 0.0001). The OR of Israeli authorship was incredibly 140.4-fold higher than the OR of the MEEI! The OR of authors of other democratic countries was also more than 100-fold the OR of authors of their undemocratic neighbors: Japan (OR = 4.93, 95%–ORCI = 3.82–6.36, P < 0.0001) vs. Russia (OR = 0.005, 95%–ORCI = 0.00–0.06, P < 0.0001); South Korea (OR = 3.48, 95%–ORCI = 2.29–5.31, P < 0.0001) vs. North Korea (OR < 0.36, 95%–ORCI = 0.00–0.35, P < 0.0001); Taiwan (OR = 5.12, 95%–ORCI = 2.85–9.19, P < 0.0001) or Hong Kong (OR = 9.21, 95%–ORCI = 3.51–24.2, P < 0.0001) vs. Mainland China (OR = 0.028, 95%–ORCI = 0.019–0.041, P < 0.0001). The OR of national authorship was closely correlated with two indices of democracy: correlation coefficient with Freedom House Index = 0.83, and correlation coefficient with the Economist’s Democracy Index = 0.76. The OR of national authorship was also (mildly less) correlated with per capita income (corr. coeff. = 0.75). In conclusion, five democracies exhibit a remarkably higher relative frequency of medical publications than their relatively undemocratic neighbors. The relative frequency of authorship was, furthermore, extremely strongly correlated with democracy and political freedom. The freedom hypothesis may help explain this phenomenon: political freedom and liberty in democracies may promote intellectual creativity and medical research. This hypothesis should be tested by a multivariate analysis of univariate risk factors of medical authorship for all nations.     

Effects of inspiratory muscle training in patients with heart failure

Aim

To investigate the effects of inspiratory muscle training (IMT) on functional capacity and balance, respiratory and peripheral muscle strength, pulmonary function, dyspnea, fatigue, depression, and quality of life in heart failure patients.

Methods

A prospective, randomized controlled, double-blinded study. Thirty patients with heart failure (NYHA II-III, LVEF<40%) were included. Sixteen patients received IMT at 40% of maximal inspiratory pressure (MIP), and 14 patients received sham therapy (15% of MIP) for 6 weeks. Functional capacity and balance, respiratory muscle strength, quadriceps femoris muscle strength, pulmonary function, dyspnea, fatigue, quality of life, and depression were evaluated.

Results

Functional capacity and balance, respiratory and peripheral muscle strength, dyspnea, depression were significantly improved in the treatment group compared with controls; quality of life and fatigue were similarly improved within groups (p < 0.05). Functional capacity (418.59 ± 123.32 to 478.56 ± 131.58 m, p < 0.001), respiratory (MIP = 62.00 ± 33.57 to 97.13 ± 32.63 cmH₂O, p < 0.001) and quadriceps femoris muscle strength (240.91 ± 106.08 to 301.82 ± 111.86 N, p < 0.001), FEV₁%, FVC% and PEF%, functional balance (52.73 ± 3.15 to 54.25 ± 2.34, p < 0.001), functional dyspnea (2.27 ± 0.88 to 1.07 ± 0.79, p < 0.001), depression (11.47 ± 7.50 to 3.20 ± 4.09, p < 0.001), quality of life, fatigue (42.73 ± 11.75 to 29.07 ± 13.96, p < 0.001) were significantly improved in the treatment group. Respiratory muscle strength (MIP = 78.64 ± 35.95 to 90.86 ± 30.23 cmH₂O, p = 0.001), FVC%, depression (14.36 ± 9.04 to 9.50 ± 10.42, p = 0.011), quality of life and fatigue (42.86 ± 12.67 to 32.93 ± 15.87, p = 0.008) were significantly improved in the control group.

Conclusion

The IMT improves functional capacity and balance, respiratory and peripheral muscle strength; decreases depression and dyspnea perception in patients with heart failure. IMT should be included effectively in pulmonary rehabilitation programs.     

Determination of the PIC700 Ceramic’s Complex Piezo-Dielectric and Elastic Matrices from Manageable Aspect Ratio Resonators

Achieving good piezoelectric properties, such as the widely reported d₃₃ charge coefficient, is a good starting point in establishing the potential applicability of piezoceramics. However, piezoceramics are only completely characterized by consistent piezoelectric-elastic-dielectric material coefficient matrices in complex form, i.e., including all losses. These matrices, which define the various alternative forms of the constitutive equations of piezoelectricity, are required for reliable virtual prototyping in the design of new devices. To meet this need, ten precise and accurate piezoelectric dielectric and elastic coefficients of the material, including all losses, must be determined for each alternative. Due to the difficulties arising from the coupling of modes when using the resonance method, this complete set of parameters is scarcely reported. Bi_0.5Na_0.5TiO₃-based solid solutions are already commercially available in Europe and Japan. Here, we report a case study of the determination of these sets of material coefficients (d_iα, g_iα, e_iα and h_iα; s^E,D_αβ and c^E,D_αβ; ε^T_ik and ε^S_ik; and β^T_ik and β^S_ik), including all losses, of the commercial PIC700 eco-piezoceramic. Plate, disk, and cylinder ceramic resonators of a manageable aspect ratio were used to obtain all the material coefficients. The validation procedure of the matrices is also given by FEA modeling of the considered resonators.     

cagA positive and negative Helicobacter pylori strains are simultaneously present in the stomach of most patients with non-ulcer dyspepsia: relevance to histological damage

^a Institute of Internal Medicine, University of Siena, Siena, Italy, ^b Institute of Pathology, University of Siena, ^c IRIS, Siena, ^d Institute of Surgical Clinics, University of Siena, ^e Institute of Internal Medicine, University of Bologna, Bologna, Italy

Correspondence to: Dr N Figura, Institute of Internal Medicine, University of Siena, Policlinico Le Scotte, viale Bracci, I-53100 Siena, Italy.

Accepted for publication 6 February 1998

Background/Aims—Infection with Helicobacter pylori strains harbouring the cagA gene (cagA+) is associated with an increased risk of developing peptic ulcer and gastric cancer. The aim of this study was to assess whether H pylori isolates with different cagA status were present in patients with non-ulcer dyspepsia, and whether a variable cagA status is relevant to histological gastric mucosal damage and glandular cell proliferation.
Methods—Well separated H pylori colonies (between 2 and 25) from primary plates, per gastric area, for each of 19 patients with non-ulcer dyspepsia were examined for cagA by hybridisation. Western blotting was used to examine both representative colonies for CagA expression and the patients' sera for antibody response to CagA. Glandular gastric cell proliferation was assessed immunohistochemically.
Results—Of the 747 colonies examined, 45.3% were cagA+. All colonies from four patients were cagA+, and all colonies from two patients were cagA−. In 13 patients (68%) both cagA+ and cagA− colonies were found. CagA expression of isolates corresponded to their cagA status. H pylori strains with different CagA molecular masses were present in three patients. Results based on all 19 patients studied showed that the prevalence of cagA+ colonies in areas with mucosal atrophy associated or not with intestinal metaplasia (67.9%) was significantly higher than in normal mucosa (44.7%) and mucosa from patients with chronic gastritis (44.0%) (p< 0.001). High levels of cell proliferation were associated with histological atrophy with or without intestinal metaplasia, but not with the possession of cagA by organisms colonising the same mucosal sites.
Conclusions—Most patients with non-ulcer dyspepsia are infected by both cagA+ and cagA− H pylori colonies. The cagA status of infecting organisms may play a role in the development of atrophy and intestinal metaplasia.
(GUT 1998;:772-778)

Keywords: gastritis; Helicobacter pylori infection;  cagA;  mucosal atrophy;  cell proliferation

     

Effect of a physical training program using the Pilates method on flexibility in elderly subjects

The adaptations of the human body resulting from the aging process especially loss of flexibility can increase the risk of falls and the risk of developing other health conditions. Exercise training, in particular the Pilates exercise method, has become an important form of physical activity that minimizes the deleterious effects of aging on flexibility. Few studies have evaluated the effect of this training method on body flexibility among elderly. We aimed to evaluate the effects of physical training using the Pilates method on body flexibility of elderly individuals. Eighteen elderly women and two elderly men (aged 70 ± 4 years) followed a 10-week Pilates training program. Individuals were recruited from the local community via open invitations. At study entry, none of them had limited mobility (walking requiring the use of walkers or canes). Furthermore, those with neurologic, muscular, or psychiatric disorders as well as those using an assistive device for ambulation were excluded secondary to limited participation. Flexibility assessment tests (flexion, extension, right and left tilt, and right and left rotation of the cervical and thoracolumbar spine; flexion, extension, abduction, and lateral and medial right and left rotation of the glenohumeral joint; flexion, extension, abduction, adduction, and lateral and medial rotation of the right and left hip; and flexion of the right and left knee) were performed by a blinded evaluator using a flexometer before and after the training period. All assessments were carried out at the same time of day. There was an observed increase in flexion (22.86 %; p < 0.001), extension (10.49 %; p < 0.036), and rotation to the left side (20.45 %; p < 0.019) of the cervical spine; flexion (16.45 %; p < 0.001), extension (23.74 %; p = 0.006), lateral bending right (39.52 %; p < 0.001) and left (38.02 %; p < 0.001), and right rotation (24.85 %; p < 0.001) and left (24.24 %; p < 0.001) of the thoracolumbar spine; flexion (right—8.80 %, p = 0.034; left—7.03 %, p = 0.050), abduction (right—20.69 %, p < 0.001; left—16.26 %, p = 0.005), and external rotation (right—116.07 % and left—143 %; p < 0.001 for both directions) of the glenohumeral joint; flexion (right—15.83 %, p = 0.050; left—9.55 %, p = 0.047) of the hips; and bending (right—14.20 %, p = 0.006; left—15.20 %, p = 0.017) the knees. The joint with the greatest magnitude of improvement was the thoracolumbar spine. Thus, this type of training may minimize the deleterious effects of aging and may improve the functionality of elderly individuals, which would reduce the likelihood of accidents (especially falls).     

Perceived Helpfulness of Physicians’ Communication Behavior and Breast Cancer Patients’ Level of Trust Over Time

OBJECTIVE  We evaluated the association between physicians’ communication behavior and breast cancer patients’ trust in their physicians. DESIGN  Longitudinal survey conducted at baseline, 2-month, and 5-month follow-up during first year of diagnosis. PARTICIPANTS  Newly diagnosed breast cancer patients (N = 246). MEASUREMENTS  We collected data on patient perceptions of the helpfulness of informational, emotional, and decision-making support provided by physicians and patients’ trust. Linear regression models evaluated the association of concurrent and prior levels of physician support with patients’ trust. RESULTS  At baseline, patients who received helpful informational, emotional, and decision-making support from physicians reported greater trust (p < 0.05, p < 0.001, and p < 0.01, respectively). At the 2-month assessment, baseline informational support and informational and emotional support at 2-months were associated with greater trust (p < 0.05, p < 0.01, and p < 0.05, respectively). At the 5-month assessment, only helpful emotional support from physicians at 5 months was associated with greater trust (p < 0.01). Interestingly, while perceived helpfulness of all three types of physician support decreased significantly over time, patient trust remained high and unchanged. CONCLUSIONS  Findings suggest that while informational and decision-making support may be more important to patient trust early in the course of treatment, emotional support from physicians may be important to maintain trust throughout the initial year of diagnosis.     

The impact of age on the diagnosis and therapy of myelodysplastic syndromes: results from a retrospective multicenter analysis in Germany

Myelodysplastic syndromes (MDS) is a disease of predominantly elderly patients with a median age of >70 yrs. However, data on the management of these patients outside of clinical trials are scarce. To assess patterns of MDS management in routine patient care with regard to the impact of age, we conducted a multicenter, representative survey of MDS health services in Germany. Data of 269 patients treated at 57 institutions were collected from preplanned chart reviews and were analyzed retrospectively. At diagnosis, median age was 70 yrs, 50% of patients had a Karnofsky index (KI) of 90%, and 12% had a comorbidity index ≥ 3 according to Sorror et al. (J Clin Oncol, 25, 2007, 4246). Cytogenetic analysis and International Prognostic Scoring System (IPSS) risk assessment were performed significantly less frequently in patients >75 yrs than in patients ≤75 yrs (P < 0.001 and P = 0.019). In bivariate analysis, potential predictors for performing IPSS risk assessment were age ≤75 yrs (y/n, P = 0.019), diagnosis at a university hospital (y/n, P = 0.001), WHO subtypes RCUD (y/n, P = 0.028), RARS (y/n, P = 0.002), or RAEB II (y/n, P = 0.037). Patients ≤75 yrs were more likely to receive active therapies (i.e., chemotherapy, immunomodulatory therapy, or epigenetic therapy) than patients >75 yrs (51% vs. 37%, P = 0.007). In bivariate analysis age ≤75 yrs (y/n, P = 0.007) was a significant predictor for active treatment with no correlation with the other predictors [IPSS risk score int‐2 or high (y/n, P = 0.005), WHO subtypes RCUD (y/n, P < 0.001), RCMD (y/n, P = 0.003), RAEB II (y/n, P < 0.001), or CMML I (y/n, P = 0.020)]. This survey confirms the impact of age on the thoroughness of MDS diagnosis and the decision for active treatment. As cytogenetic analysis and risk assessment are essential for the choice of appropriate therapy, elderly patients in particular may not be receiving adequate treatment.     

Inpatientvs. outpatient bowel preparation for elective colorectal surgery

BACKGROUND: Recent pressures to decrease the cost of medical care have mandated preoperative outpatient bowel preparation (OBP) for elective colorectal surgery without any data documenting equivalent quality of care. This study examined the safety and efficacy of OBP compared with inpatient bowel preparation (IBP). METHODS: Records of all patients who underwent OBP for elective colorectal resection since the inception of the OBP program from July 1993 to June 1994 were compared with records of all patients who received IBP for elective procedures from January to June 1993. RESULTS: The two groups, 90 patients who underwent OBP and 98 patient who had IBP, were well matched for age, sex, diagnosis, and operations performed. The OBP group had a shorter length of hospital stay (median, 7 vs. 9 days; P < 0.0001; chi-squared analysis), whereas the complication rate was similar (19 percent in the OBP group vs. 18 percent in the IBP group), including infectious complications (10 percent in the OBP group vs. 7 percent in the IBP group). Although operating time was similar (mean, 199 vs. 213 minutes) and estimated blood loss (mean, 528 vs. 536 ml), the OBP group had significantly higher perioperative fluid requirements: intraoperative fluids (median, 4300 vs. 3700 ml; P < 0.05; Student's t-test), intraoperative colloid administration (48 vs. 29 percent; P < 0.0002; chi-squared), 24-hour postoperative fluids (3224 vs. 2700 ml; P < 0.0001; Student's t-test), and postoperative fluid challenges (50 vs. 20 percent; P <0.0001; chi-squared analysis). CONCLUSION: Outpatient bowel preparation for elective colorectal surgery is safe and effective. It offers shorter hospital stay, and, therefore, potentially reduces medical care cost. Patients with multiple medical problems may not tolerate extensive fluid shifts; therefore, other preoperative arrangements, such as inpatient or outpatient intravenous fluid therapy, need to be considered to minimize complications that may outweigh potential cost savings.Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Montreal, Quebec, Canada, May 7 to 12, 1995.     

Prevalence and correlates of fear of falling in Korean community-dwelling elderly subjects

Purpose

This study was conducted to investigate the factors related to fear of falling in elderly subjects, with a view to developing interventions to prevent falls.

Methods

Data from 9033 elderly subjects aged ≥ 65 years were analyzed from the 2008 National Elderly Survey of the Korea Ministry of Health & Welfare.

Results

In total, 76.6% of elderly Korean subjects had fear of falling. Factors associated with an increased risk of fear of falling in elderly subjects were, in order from highest to lowest, previous experience of falling (odds ratio [OR] = 6.41, p < 0.001), experience of body pain (OR = 2.45, p < 0.001), lower perceived health status (OR = 1.89, p < 0.001), presence of depression (OR = 1.82, p < 0.001), receipt of more doses of drugs per day for those receiving 1–2 (OR = 1.72, p < 0.001) or ≥ 3 doses of drugs per day (OR = 1.67, p = 0.001), older age (OR = 1.68, p < 0.001), female gender (OR = 1.64, p < 0.001), dependence for instrumental activities of daily living (OR = 1.55, p < 0.001), dependence for activities of daily living (OR = 1.44, p = 0.017), and lower education level (OR = 1.18, p = 0.016).

Conclusion

The fear of falling can be attenuated by providing interventions to reduce the impact of modifiable risk factors that were identified in this study.