Markers of atherosclerosis in patients with Cushing’s syndrome: a meta-analysis of literature studies

Background: Several studies reported an increased cardiovascular (CV) risk in Cushing’s syndrome (CS). We performed a meta-analysis on the impact of CS on major markers of atherosclerosis.

Methods: Studies on intima-media thickness (IMT), carotid plaques prevalence, and flow-mediated dilation (FMD) in CS patients and controls were searched in the PubMed, Web of Science, Scopus, and EMBASE. Differences between cases and controls were expressed as mean difference (MD) with 95% confidence intervals (95%CI) for continuous variables, and as Odds Ratio (OR) with 95%CI for dichotomous variables.

Results: Fourteen studies (332 CS, 462 controls) were included. Compared with controls, CS patients showed higher IMT (MD: 0.20?mm; 95%?CI: 0.12, 0.28; p?Conclusions: CS is significantly associated with markers of subclinical atherosclerosis and CV risk. These findings could help establish more specific CV prevention strategies in this clinical setting.

• Key messages

• A series of studies reported an increased cardiovascular risk in patients with Cushing’s syndrome (CS).

• In the present meta-analysis we demonstrated that CS is associated with an increased intima-media thickness, higher prevalence of carotid plaques, and lower flow-mediated dilation as compared with controls.

• These data consistently suggest the need for a strict monitoring of early signs of subclinical atherosclerosis in CS patients

     

Prevalence,incidence and mortality of inflammatory bowel disease in Catalonia. A population-based analysis

Abstract

Introduction: Few recent data on the epidemiology of inflammatory bowel disease (IBD) are available, especially in Southern Europe.

Aim: To evaluate the prevalence, incidence and mortality of IBD in Catalonia during the period 2011–2016.

Material and methods: Data on the prevalence, incidence and mortality of IBD were obtained from the Catalan Health Surveillance System (CHSS). Crude incidence and prevalence rates were calculated for all the Catalan population. Trends in age-sex-adjusted rates were also estimated, and logistic regression was used to calculate the adjusted mortality odds ratio (OR). Data for Crohn’s disease (CD) and ulcerative colitis (UC) were analyzed separately.

Results: The prevalence per 100,000 inhabitants in 2016 was 353.9 for UC and 191.4 for CD. The total number of IBD patients rose from 29543 in 2011 to 40614 in 2016. IBD was associated with significantly elevated adjusted mortality ratios: 1.28 (95% CI: 1.6–1.4) for UC and 1.85 (95% CI: 1.62–2.12) for CD.

Conclusions: IBD prevalence is very high and is increasing rapidly in Catalonia. Both CD and UC are associated with significantly higher mortality rates.

• Key message

• Crohn disease and ulcerative colitis present a small but significant increase in mortality compared to non-inflammatory bowel disease.

• The prevalence of inflammatory bowel disease is increasing rapidly in Catalonia.

• Data on prevalence and incidence suggest that the number of patients may double in approximately 10 years.

     

Effectiveness of neuromuscular taping on painful hemiplegic shoulder: a randomised clinical trial

Purpose: The purpose of this trial was to investigate changes in pain, the range of motion (ROM) and spasticity in people with painful hemiplegic shoulder (PHS) after the application of an upper limb neuromuscular taping (NMT). Methods: We conducted a randomised clinical trial. The study included 32 people, 31% female (mean?±?SD age: 66?±?9 years), with PHS after stroke with pain at rest and during functional movements. The experimental group received the application of NMT and a standard physical therapy programme (SPTP), whereas the control group received SPTP. The groups received four 45-minute long sessions over four weeks. The VAS, ROM and spasticity were assessed before and after the intervention with follow-up at four weeks. Results: The experimental group had a greater reduction in pain compared to the control group at the end of the intervention, as well as at one month after the intervention (p?Conclusion: Our study demonstrates that NMT decreases pain and increases the ROM in subjects with shoulder pain after a stroke.

• Implications for Rehabilitation

• Painful hemiplegic shoulder is a frequent complication after stroke with negative impacts on functional activities and on quality of life of people, moreover restricts rehabilitation intervention.

• Neuromuscular taping is a technique introduced by David Blow for the treatment of neuromuscoloskeletal problems.

• This study shows the reduction of pain and the improvement of range of motion after the application of an upper limb neuromuscular taping.

• Rehabilitation professionals who are involved in the management of painful hemiplegic shoulder may like to consider the benefits that neuromuscular taping can produce on upper limb.

     

Awareness of hypertension and depressive symptoms: a cross-sectional study in a primary care population

Objective: To investigate the association of hypertension awareness and depressive symptoms, and to analyse factors predisposing aware hypertensives to depressive symptoms.

Design: Cross-sectional study in a primary care population.

Setting: Cardiovascular risk factor survey in two semi-rural towns in Finland.

Subjects: Two thousand six hundred seventy-six middle-aged risk persons without an established cardiovascular or renal disease or type 2 diabetes.

Main outcome measures: Depressive symptoms, previous and new diagnosis of hypertension.

Results: Hypertension was diagnosed in 47.9% of the subjects, of whom 34.5% (442/1 282) had previously undetected hypertension. Depressive symptoms were reported by 14% of the subjects previously aware of their hypertension, and by 9% of both unaware hypertensives and normotensive subjects. In the logistic regression analysis, both the normotensive (OR 0.62, 95% CI 0.45–0.86) (p?=?0.0038) and the unaware hypertensive subjects (OR 0.54, 95% CI 0.35–0.84) (p?=?0.0067) had lower risk for depressive symptoms than the previously diagnosed hypertensives. Among these aware hypertensives, female gender (OR 3.61, 95% CI 2.06–6.32), harmful alcohol use (OR 2.55, 95% CI 1.40–4.64) and obesity (OR 2.50, 95% CI 1.01–6.21) predicted depressive symptoms. Non-smoking (OR 0.57, 95% Cl 0.33–0.99) and moderate leisure-time physical activity compared to low (OR 0.53, 95% CI 0.33–0.84) seemed to buffer against depressive symptoms.

Conclusion: Depressive symptoms are common in hypertensive persons even without comorbidities, if the person is already aware of his/her hypertension. Many modifiable, lifestyle associated factors may contribute to the association of hypertension and depressive symptoms.

• Key Points

• Hypertension and depressive symptoms are known to form a toxic combination contributing even to all-cause mortality.

• Comorbidities or the labelling effect of the diagnosis of hypertension can confound their association.

• Our study shows that depressive symptoms are common in hypertensive persons even without comorbidities, if the person is already aware of his/her hypertension.

• Many modifiable, lifestyle-associated factors may contribute to the association of hypertension and depressive symptoms.

• When treating hypertensive patients, consideration of depressive symptoms is important in order to promote favorable lifestyle and control of hypertension.

     

Intrathecal Baclofen: A discussion on impact that medical advances can have on the individual and the implications this has for a society that is built on an ethic of social medicine

Purpose: This paper describes a study in which patients with neuromuscular disease (NMD) were engaged to list top-priorities for scientific research in order to complement the researchers’ agenda. Method: A dialogic model for research agenda setting was used. Interviews, focus groups and expert meetings with patients were held to identify research topics. Research topics were prioritized via a questionnaire. Agendas were integrated in a dialogue meeting with professionals and patients. Results: The research agenda of NMD patients is divided in four research domains, with a total of 24 research topics. These domains include (1) health; (2) quality of life; (3)quality of care and support, and (4) basic issues. Among the research domains highest priority was given to research on health, followed by research on quality of life. Conclusions: Both patients and professionals agreed a proper balance needs to be found between fundamental research and research on symptomatic treatment and quality of life. They concluded that more attention is required for research on the effective treatment of symptoms, quality of life and implementation of knowledge about NMD in regular care.

Implications for Rehabilitation

Neuromuscular disease

• Patients with neuromuscular disease (NMD) can effectively participate in a research agenda setting process, contributing with their own perspectives on research topics.

• Concerning rehabilitation research, patients give priority to research on movement and training (quality of care domain), and on partner support (quality of life domain).

• The patient-driven agenda reinforces the wide scope on rehabilitation encapsulated in the ICF model and both stipulates the need for more interdisciplinary research, as well as the implementation of research in rehabilitation practice.

     

A comparison of swallowing dysfunction in Becker muscular dystrophy and Duchenne muscular dystrophy

Purpose: Swallowing dysfunction has been reported in Duchenne muscular dystrophy (DMD), but has not been studied in Becker muscular dystrophy (BMD). The aims of this study were to report the characteristics of swallowing dysfunction in BMD compared with DMD.

Materials and methods: The study participants were 18 patients with BMD and 18 patients with DMD. All the patients were examined using videofluorography during swallowing of 5?mL of fluid. The penetration–aspiration scale (P–A scale) and the videofluorographic dysphagia scale (VDS) were used to evaluate dysphagia.

Results: Swinyard functional ability stage was not significantly different between the BMD and DMD groups. Rate of aspiration, P–A scale score, and total VDS score did not differ across groups, but the VDS item score for laryngeal elevation was lower in the BMD group than in the DMD group (median scores 4.5 and 9, respectively; p?r?=?0.78, p?Conclusion: Patients with BMD have swallowing problems similar to those observed in patients with DMD when matched according to physical functional status. These patients should be evaluated and followed-up for the duration of their disease.

• Implications for rehabiliation

• Dysphagia is one of the most critical problems in patients with progressive neuromuscular disease but dysphagia in patients with Becker muscular dystrophy (BMD) was not well known.

• Eighteen patients with BMD and 18 patients with Duchenne muscular dystrophy were examined with videofluorography.

• Patients with BMD have swallowing problems similar to those observed in patients with DMD.

     

Invasive pulmonary aspergillosis in patients with solid tumours: risk factors and predictors of clinical outcomes

Abstract

Background: The characteristics and management of invasive pulmonary aspergillosis (IPA) in patients with hematologic malignancies are well known, but IPA in patients with solid tumours is not well described.

Methods: We retrospectively reviewed all Aspergillus-positive cultures at a tertiary cancer center during 2004–2017. We identified 101 patients with IPA and solid tumours. We analyzed the association between clinical features and treatment and 12-week mortality and response to antifungal therapy.

Results: Fifty-one patients had lung cancer, 77 had underlying lung disease, 47 received chest radiation and 33 had chronic obstructive pulmonary disease. Aspergillus fumigatus was the most common type isolated (71%); 68 patients (70%) were treated with voriconazole monotherapy. Independent risk factors for 12-week mortality included receiving steroids within 30 days of diagnosis (hazard ratio 2.2, 95% confidence interval [CI]: 1.1–4.6; p?=?.03) and chest radiotherapy (hazard ratio 2.6, 95% CI: 1.2–5.5; p?=?.01). In multivariate analysis, a positive fungal stain was associated with lower odds of a successful response (odds ratio 0.2; 95% CI: 0.05–0.75; p?=?.02), whereas voriconazole treatment was associated with higher odds (odds ratio 10.1; 95% CI: 2.1–48.5; p?<?.01).

Conclusions: IPA should be considered in patients with solid tumours, particularly those with underlying lung disease.

• Key messages

• Invasive pulmonary aspergillosis should be considered in patients with solid tumours, particularly those with underlying lung disease, lung cancer and those who received chest radiotherapy.

• Most of the patients with invasive pulmonary aspergillosis and solid tumours presented with nonspecific symptoms and signs as well as nonspecific CT findings. Unlike patients with hematologic malignancies, fever and hemoptysis were not predominant symptoms and the classical halo sign and the air-crescent sign were not described.

• Independent risk factors for 12-week mortality included receiving steroids within 30 days of diagnosis and chest radiotherapy. In multivariate analysis, a positive fungal stain was associated with lower odds of a successful response to antifungal therapy, whereas voriconazole treatment was associated with higher odds.

     

Shoulder pain in the Swiss spinal cord injury community: prevalence and associated factors

Purpose: To determine the prevalence of shoulder pain and to identify factors associated with shoulder pain in a nationwide survey of individuals living with spinal cord injury (SCI) in Switzerland.

Methods: Data was collected through the 2012 community survey of the Swiss SCI Cohort Study (SwiSCI) (N?=?1549; age 52.3?±?14.8; 29% female). Sociodemographic and socioeconomic circumstances, SCI characteristics, health conditions as well as mobility independence and sporting activities were evaluated as predictor variables. Analyses were adjusted for item non-response (using multiple imputation) and unit-nonresponse (using inverse probability weighting).

Results: The adjusted prevalence of shoulder pain was 35.8% (95% CI: 33.4–38.3). Multivariable regression analysis revealed higher odds of shoulder pain in females as compared to males (odds ratio: 1.89; 95% CI: 1.44–2.47), and when spasticity (1.36; 1.00–1.85) and contractures (2.47; 1.91–3.19) were apparent. Individuals with complete paraplegia (1.62; 1.13–2.32) or any tetraplegia (complete: 1.63; 1.01–2.62; incomplete: 1.82; 1.30–2.56) showed higher odds of shoulder pain compared to those with incomplete paraplegia.

Conclusions: This survey revealed a high prevalence of shoulder pain. Sex, SCI severity, and specific health conditions were associated with having shoulder pain.

• Implications for rehabilitation

• Individuals with spinal cord injury have a high prevalence of shoulder pain.

• Females, individuals with complete paraplegia or any tetraplegia and individuals with contractures and spasticity should receive considerable attention in rehabilitation programmes due to their increased odds of having shoulder pain.

     

Adaptations from the prosthetic and intact limb during standing on a sway-referenced support surface for transtibial prosthesis users

Abstract

Purpose: To investigate the bilateral postural adaptations as a result of standing on an increasingly unstable sway-referenced support surface with both the intact and prosthetic limb for transtibial prosthesis users (TPUs).

Method: TPUs (n = 14) and matched controls (n = 14) stood quietly in multiple foot placement conditions (intact foot, prosthetic foot and both feet) on a sway-referenced support surface which matched surface rotation to the movement of the centre of pressure (CoP). Force and motion data were collected and used to analyse CoP mean position, displacement integral and force components under intact and prosthetic limbs.

Results: Significant differences were found between prosthesis users and controls in CoP mean position in anteroposterior (1.5 (95% CI, 1.2–1.8) cm) and mediolateral directions (3.1 (95% CI, 0.5–5.7) cm. CoP displacement integrals were significantly different greater for prosthesis user group in the anteroposterior direction. Force components differences were found in all planes (anteroposterior: 0.6 (95% CI, 0.4–0.8 N); mediolateral: 0.1 (95% CI, 0.0–0.2 N & 0.3 (95% CI, 0.2–0.4) N, inferosuperior: 2.2 (95% CI, 1.4–3.0) N).

Conclusions: TPUs have bilateral static and dynamic postural adaptations when standing on a sway-referenced support surface that is different to controls, and between prosthetic and intact sides. Results further support evidence highlighting importance of the intact limb in maintenance of postural control in prosthesis users. Differences indicate clinical treatment should be directed towards improving outcomes on the intact side.

• Implications for rehabilitation

• Prosthesis users have bilateral adaptations when standing on a sway referenced support surface

• These adaptations are different to controls, and between prosthetic and intact sides.

• The intact limb is the major contributor to maintenance of postural control in prosthesis users.

• Clinical treatment should account for this when interventions are designed.

     

Limited value of NT-proBNP as a prognostic marker of all-cause mortality in patients with heart failure with preserved and mid-range ejection fraction in primary care: A report from the swedish heart failure register

Abstract

Aim: The prognostic value of natriuretic peptides in the management of heart failure (HF) patients with ejection fraction (EF) <40% is well established, but is less known for those with EF ≥40% managed in primary care (PC). Therefore, the aim of this study is to describe the prognostic significance of plasma NT-proBNP in such patients managed in PC.

Subjects: We included 924 HF patients (48% women) with EF ≥40% and NT-proBNP registered in the Swedish Heart Failure Registry. Follow-up was 1100?±?687?days.

Results: One-, three- and five-year mortality rates were 8.1%, 23.9% and 44.7% in patients with EF 40–50% (HFmrEF) and 7.3%, 23.6% and 37.2% in patients with EF ≥50% (HFpEF) (p?=?0.26). Patients with the highest mean values of NT-proBNP had the highest all-cause mortality but wide standard deviations (SDs). In univariate regression analysis, there was an association only between NT-proBNP quartiles and all-cause mortality. In HFmrEF patients, hazard ratio (HR) was 1.96 (95% CI 1.60–2.39) p?<?0.0001) and in HFpEF patients, HR was 1.72 (95% CI 1.49–1.98) p?<?0.0001). In a multivariate Cox proportional hazard regression analysis, adjusted for age, NYHA class, atrial fibrillation and GFR class, this association remained regarding NT-proBNP quartiles [HR 1.83 (95% CI 1.38–2.44), p?<?0.0001] and [HR 1.48 (95% CI 1.16–1.90), p?=?0.0001], HFmrEF and HFpEF, respectively.

Conclusion: NT-proBNP has a prognostic value in patients with HF and EF ≥40% managed in PC. However, its clinical utility is limited due to high SDs and the fact that it is not independent in this population which is characterized by high age and much comorbidity.

• Key points

• It is uncertain whether NT-proBNP predicts risk in heart failure with preserved ejection fraction (EF?>?40%, HFpEF) managed in primary care.

• We show that high NT-proBNP predicts increased all-cause mortality in HFpEF-patients managed in primary care.

• The clinical use is however limited due to large standard deviations, many co-morbidities and high age.

• Many of these co-morbidities contribute to all-cause mortality and management of these patients should also focus on these co-morbidities.

     

Validation of the Zung self-rating depression scale (SDS) in older adults

Abstract

Objective: The main objective of this study was to investigate the psychometric properties of the Zung Self-Rating Depression Scale (SDS) and evaluate screening parameters capability of the SDS with the Beck Depression Inventory (BDI-21) among the elderly population.

Design: A population-based study

Setting: Community

Subjects: 520 adults, aged 72–73 years, living in the city of Oulu, Finland.

Main outcome measures: The screening parameters of the SDS questions and BDI-21 for detecting severity of depression. The Mini Neuropsychiatric Interview for diagnosing major depression.

Results: The optimal cut-off point for the SDS was 39. The sensitivity and specificity parameters for this cut-off point were 79.2% (95% CI 57.8–92.9) and 72.2% (95% CI 67.9–76.1), respectively. Positive and negative predictive values were 12.5% (95% CI 7.7–18.8) and 98.6% (95% CI 96.7–99.5), respectively. Moreover, there was no statistically significant difference in diagnostic accuracy indices of the cut-off points 39 and 40. In a receiver operating characteristic analysis, the area under the curve was 0.85 (95%CI 0.77–0.92) for the SDS total score and 0.89 (95% CI 0.83-0.96) for the BDI-21 (p?=?0.137).

Conclusion: Using the traditional cut-off point, the SDS was convenient for identifying clinically meaningful depressive symptoms in an elderly Finnish population when compared with the BDI-21 which is one of the most commonly used depression screening scales. The sensitivity and specificity of these two screening tools are comparable.

Based on our study, the SDS is convenient for identifying clinically meaningful depressive symptoms among older adults at the community level.

• Key points

• The widely used Zung Self-Rating Depression Scale (SDS) has not previously been validated among elderly people at the community level.

• The sensitivity and specificity of SDS (cut-off point 39) were 79.2% and 72.2%.

• The positive and negative predictive values for SDS were 12.5% and 98.6%.

• SDS is convenient for identifying major depression in an elderly population and regarding sensitivity and specificity comparable to BDI-21.

     

Exploring quality of life in people with slowly-progressive neuromuscular disease

Purpose: A qualitative work is conducted to enable later the construction of a health-related quality of life (HRQL) questionnaire for patients with slowly-progressive neuromuscular disease (NMD) such as myopathies and muscular dystrophies.

Methods: The formation of focus groups is an efficient method to perform an in-depth exploration of the aspects of HRQL potentially impaired by NMD. Patients were recruited in France by 4 NMD reference centers. To ensure adequate representativeness in terms of severity, three types of focus groups were formed: (1) Patients able to walk (WP). (2) Patients using a wheelchair (WCP). (3) Patients using a wheelchair and requiring continuous mechanical ventilation (WCMVP). All verbal interactions among group participants were recorded. A qualitative analysis of the verbatim was performed using the framework of the International Classification of Functioning, Disability and Health model (ICF).

Results: A total of 41 patients distributed across five focus groups were interviewed. The verbatim provided 2424 ICF categories. The percentages of mentions of the different ICF categories were calculated and graphically displayed.

Conclusion: The results enabled to identify and quantify the aspects of life that are altered by NMD according to patients. This qualitative work was the first phase of a more ambitious project to develop a new NMD-specific HRQL questionnaire.

• Implication of rehabilitation

• Patients with NMD have more to say about the quality of their environment, their social relationships and their psychological state than about their physical symptoms.

• This observation should be compared to clinician perceptions which often focus mainly on the physical symptoms, overlooking those elements that they cannot assess directly.

• Many patients reported relationship issues with various people from their surrounding (e.g., health professionals, acquaintances, colleagues, and strangers).

• In particular, it is essential that health professionals are careful not to make adult patients with NMD feel infantilized.

• This issue can be addressed by making all relevant medical information available and asking for the patient's opinion on any important change in their medical care.

     

Intertester reliability of shoulder complaints diagnoses in primary health care

Objective: Shoulder complaints are frequently encountered in general practice, but precise diagnosing is challenging. This study investigated agreement of shoulder complaints diagnoses between clinicians in a primary health care setting.

Design: Cross-sectional study.

Setting: Four primary health care clinicians used patients’ history and functional examination of the shoulder by selective tissue tension techniques (STTs), to diagnose shoulder complaints.

Subjects: 62 patients, aged 18–75 years.

Main outcome measure: Reliability of diagnoses was assessed by observed intertester agreement and Cohen’s kappa. A total of 372 diagnostic pairs were available for intertester comparisons.

Results: Six diagnoses were assigned by all clinicians; supraspinatus-, infraspinatus-, subscapularis-tendinopathies; chronic subacromial bursitis; glenohumeral capsulitis, and acromioclavicular joint lesion. The observed agreement on these diagnoses ranged from 0.84 for glenohumeral capsulitis to 0.97 for acromioclavicular joint lesion. Kappa scores were 0.46 (95% CI 0.33, 0.58) for chronic subacromial bursitis; 0.53 (95% CI 0.34, 0.68), 0.59 (95% CI 0.47, 0.70), and 0.68 (95% CI 0.53, 0.82) for infraspinatus -, supraspinatus -, and subscapularis-tendinopathy, respectively. For glenohumeral capsulitis and acromioclavicular lesion kappa scores were 0.66 (95% CI 0.57, 0.73) and 0.78 (95% CI 0.61, 0.90). Kappa scores were higher for individual diagnoses than for individual tests, except for limitation in passive abduction (0.70, 95% CI 0.62, 0.78) and passive lateral rotation (0.66, 95% CI 0.57, 0.73).

Conclusions: Although experienced clinicians showed substantial intertester agreement, precise diagnoses of shoulder complaints in primary health care remain a challenge. The present results call for further research on refined diagnoses of shoulder complaints.

• Key points

• Based on medical history and a systematic functional examination by selective tissue tension techniques (STTs), we investigated the agreement of shoulder complaints diagnoses across four primary health care clinicians and 62 patients.

• ??Agreements on diagnoses were generally better than the agreement on individual tests.

• ??Good kappa scores were obtained for the diagnoses glenohumeral capsulitis, rotator cuff tendinopathy, and acromioclavicular lesion.

• ??Further research is necessary to investigate the diagnostic validity of functional shoulder examination by the STTs method.

     

Subclinical carotid atherosclerosis in patients with chronic obstructive pulmonary disease: a meta-analysis of literature studies

Background: Chronic obstructive pulmonary disease (COPD) patients have an increased cardiovascular (CV) morbidity and mortality. Common carotid intima-media thickness (CCA-IMT) and carotid plaques are surrogate markers of subclinical atherosclerosis and predictors of CV events.

Methods and results: We performed a meta-analysis to evaluate the association between COPD and subclinical atherosclerosis. Studies evaluating the impact of COPD on CCA-IMT and on the prevalence of carotid plaques were systematically searched.

Results: Twenty studies (2082 COPD patients and 4844 controls) were included, 12 studies with data on CCA-IMT (13 data-sets on 1180 COPD patients and 2312 controls) and 12 studies reporting on the prevalence of carotid plaques (1231 COPD patients and 4222 controls). Compared to controls, COPD patients showed a significantly higher CCA-IMT (mean difference [MD]: 0.201?mm; 95%CI: 0.142, 0.260; p?p?Conclusions: COPD is significantly associated with subclinical atherosclerosis. These findings may be useful to plan adequate CV prevention strategies.

• Key messages

• COPD patients show a higher CCA-IMT and an increased prevalence of carotid plaques compared with controls.

• A more severe pulmonary disease is associated with a higher prevalence of carotid plaques in COPD patients.

• Screening for subclinical atherosclerosis may be worthy in COPD patients to plan specific prevention strategies.

     

Predictors of Symptom Duration and Bacteriuria in Uncomplicated Urinary Tract Infection

Abstract

Objective: To identify baseline predictors of symptom duration after empirical treatment for uncomplicated urinary tract infection (UTI) and significant bacteriuria in a cohort of women treated for UTI.

Design: Prospective single-centre cohort study.

Setting: Outpatient clinic in Norway.

Patients: From September 2010 to November 2011, 441 women aged 16–55 years with symptoms of uncomplicated UTI were included.

Results: Dipstick findings of leukocyte esterase 1?+?(incidence rate ratio (IRR) 1.93, 95% confidence interval (CI) 1.23–3.01, p?<?0.01) and microbe resistant to mecillinam treatment (IRR 1.41, 95% CI 1.07–1.89, p?=?0.02) predicted longer symptom duration. More pronounced symptoms did not predict longer symptom duration (IRR 1.18, 95% CI 0.94–1.46, p?=?0.15) or significant bacteriuria (odds ratio [OR] 1.16, 95% CI 0.72–1.88, p?=?0.54). Leukocyte esterase 2?+?(OR 2.51, 95% CI 0.92–6.83, p?=?0.07) or 3?+?(OR 2.40, 95% CI 0.88–6.05, p?=?0.09) and nitrite positive urine dipstick test (OR 3.22, 95% CI 1.58–7.01, p?=?<0.01) were associated with bacteriuria.

Conclusion: More pronounced symptoms did not correlate with significant bacteriuria or symptom duration after empirical treatment for acute cystitis. One might reconsider the current practice of treating uncomplicated UTI based on symptoms alone.

• Key Points

• Treatment strategies for milder infectious diseases must consider ways of reducing antibiotic consumption to decelerate the increase in antibiotic resistance. Our findings suggest that more emphasis should be put on urine dipstick results and bacteriological findings in the clinical setting. One might reconsider the current practice of treating uncomplicated UTIs based on symptoms alone.

     

Dysphagia in Duchenne muscular dystrophy: practical recommendations to guide management

Purpose: Duchenne muscular dystrophy (DMD) is a rapidly progressive neuromuscular disorder causing weakness of the skeletal, respiratory, cardiac and oropharyngeal muscles with up to one third of young men reporting difficulty swallowing (dysphagia). Recent studies on dysphagia in DMD clarify the pathophysiology of swallowing disorders and offer new tools for its assessment but little guidance is available for its management. This paper aims to provide a step-by-step algorithm to facilitate clinical decisions regarding dysphagia management in this patient population.

Methods: This algorithm is based on 30 years of clinical experience with DMD in a specialised Centre for Neuromuscular Disorders (Inkendaal Rehabilitation Hospital, Belgium) and is supported by literature where available.

Results: Dysphagia can worsen the condition of ageing patients with DMD. Apart from the difficulties of chewing and oral fragmentation of the food bolus, dysphagia is rather a consequence of an impairment in the pharyngeal phase of swallowing. By contrast with central neurologic disorders, dysphagia in DMD accompanies solid rather than liquid intake. Symptoms of dysphagia may not be clinically evident; however laryngeal food penetration, accumulation of food residue in the pharynx and/or true laryngeal food aspiration may occur. The prevalence of these issues in DMD is likely underestimated.

Conclusions: There is little guidance available for clinicians to manage dysphagia and improve feeding for young men with DMD. This report aims to provide a clinical algorithm to facilitate the diagnosis of dysphagia, to identify the symptoms and to propose practical recommendations to treat dysphagia in the adult DMD population.

• Implications for Rehabilitation

• Little guidance is available for the management of dysphagia in Duchenne dystrophy.

• Food can penetrate the vestibule, accumulate as residue or cause aspiration.

• We propose recommendations and an algorithm to guide management of dysphagia.

• Penetration/residue accumulation: prohibit solid food and promote intake of fluids.

• Aspiration: if cough augmentation techniques are ineffective, consider tracheostomy.

     

Profile of disabilities and their associated factors in patients with type 2 diabetes evaluated by the Canadian occupational performance measure: the Rio De Janeiro type 2 diabetes cohort study

Purpose: To investigate the profile of disability in patients with type 2 diabetes and to evaluate its associated variables.

Method: The Canadian Occupational Performance Measure (COPM) assessed disabilities in 475 type 2 diabetic individuals. The activities were categorised by the International Classification of Functioning, Disability and Health. The Medical Outcomes Study 36-item Short-Form Health Survey (SF-36) was used to evaluate pain, emotional and physical functioning domains of life-quality. Multivariable logistic regression assessed the independent correlates of better/worse performance.

Results:: Median COPM score was 4.5 (interquartile range 3–6). Problems in mobility (53.6%), self-care (21.1%) and daily-life (13.0%) were most frequently self-reported. Presence of restriction/pain in the upper limbs (odds ratio [OR]: 1.66; 95% CI: 1.11–2.47; p=0.013) and of peripheral neuropathy (OR: 1.64; 95% CI: 1.06–2.53; p=0.026) were associated with greater chance of worse performance. Higher values of SF-36 in pain and emotional domains (each 10 point increase; OR: 0.92 95% CI: 0.85–0.98; p=0.011; OR: 0.96; 95% CI: 0.92–1.00; p=0.063, respectively) and physical activity (OR: 0.63; 95% CI: 0.41–0.98; p=0.042) were associated with better performance.

Conclusions:: Type 2 diabetic patients frequently reported disabilities in mobility, self-care and daily-life domains; and its associated factors were the presence of depression, upper limb pain and diabetic peripheral neuropathy.

• Implications for Rehabilitation

• The Canadian Occupational Performance Measure (COPM) instrument can be applied to patients with diabetes, as it identifies several disabilities, mostly in mobility, self-care and domestic life areas.

• Rehabilitation directed to upper limb pain/limitation and to lower limb peripheral neuropathy shall be implemented and may improve diabetic patients’ performance and quality of life.

• A patient-centered rehabilitation strategy, guided by the COPM, may enable greater independence and autonomy, but this should be confirmed in future intervention studies.

     

Reliability,validity, and norms of the 2-min walk test in children with and without neuromuscular disorders aged 6–12

Purpose: The 2-min walk test may be more appropriate functional exercise test for young children. This study aimed to examine the 2-min walk test’s reliability; validity; and minimal clinically important difference; and to establish norms for children aged 6–12.

Methods: Sixty-one healthy children were recruited to examine the 2-min walk test’s reliability. Forty-six children with neuromuscular disorders (63% cerebral palsy) were recruited to test the validity. The normative study involved 716 healthy children without neuromuscular disorders (male?=?51%, female?=?49%). They walked at a self-selected speed for 2?min along a smooth, flat path 15 m in length.

Results: The mean distance covered in the 2-min walk test was 152.8 m (SD?=27.5). No significant difference was found in the children’s test-retest results (p?>?0.05). The intra- and inter-rater reliability were high (all intra-class correlation coefficients >0.8). All children, except one with neuromuscular disorders, completed the 2-min walk test, of which the minimal clinically important difference at 95% confidence interval was 23.2 m for the entire group, 15.7 m for children walking with aids, and 16.6 m for those walking independently.

Conclusions: The 2-min walk test is a feasible, reliable, and valid exercise test for children with and without neuromuscular disorders aged 6–12. The first normative references and minimal clinically important difference for children with neuromuscular disorders were established for children of this age group.

• Implications for rehabilitation

• The 2-min walk test is a feasible, safe, reliable, and valid time-based walk test for children aged 6–12 years.

• Normative references have been established for healthy children aged 6–12 years.

• Minimal clinically important difference at 95% confidence interval were calculated for children with neuromuscular disorders who walked without aids (i.e., independent and stand-by supervision) and those who walked with aids equal to 16.6 and 15.7 m, respectively.

• Distance covered by the healthy children in the 2?min did not correlate with age, gender, height, and weight of the children.

     

Global epidemiology of diabetic foot ulceration: a systematic review and meta-analysis†

Diabetic foot is a severe public health issue, yet rare studies investigated its global epidemiology. Here we performed a systematic review and meta-analysis through searching PubMed, EMBASE, ISI Web of science, and Cochrane database. We found that that global diabetic foot ulcer prevalence was 6.3% (95%CI: 5.4–7.3%), which was higher in males (4.5%, 95%CI: 3.7–5.2%) than in females (3.5%, 95%CI: 2.8–4.2%), and higher in type 2 diabetic patients (6.4%, 95%CI: 4.6–8.1%) than in type 1 diabetics (5.5%, 95%CI: 3.2–7.7%). North America had the highest prevalence (13.0%, 95%CI: 10.0–15.9%), Oceania had the lowest (3.0%, 95% CI: 0.9–5.0%), and the prevalence in Asia, Europe, and Africa were 5.5% (95%CI: 4.6–6.4%), 5.1% (95%CI: 4.1–6.0%), and 7.2% (95%CI: 5.1–9.3%), respectively. Australia has the lowest (1.5%, 95%CI: 0.7–2.4%) and Belgium has the highest prevalence (16.6%, 95%CI: 10.7–22.4%), followed by Canada (14.8%, 95%CI: 9.4–20.1%) and USA (13.0%, 95%CI: 8.3–17.7%). The patients with diabetic foot ulcer were older, had a lower body mass index, longer diabetic duration, and had more hypertension, diabetic retinopathy, and smoking history than patients without diabetic foot ulceration. Our results provide suggestions for policy makers in deciding preventing strategy of diabetic foot ulceration in the future.

• Key messages

• Global prevalence of diabetic foot is 6.3% (95%CI: 5.4–7.3%), and the prevalence in North America, Asia, Europe, Africa and Oceania was 13.0% (95%CI: 10.0–15.9%), 5.5% (95%CI: 4.6–6.4%), 5.1% (95%CI: 4.1–6.0%), 7.2% (95%CI: 5.1–9.3%), and 3.0% (95% CI: 0.9–5.0%).

• Diabetic foot was more prevalent in males than in females, and more prevalent in type 2 diabetic foot patients than in type 1 diabetic foot patients.

• The patients with diabetic foot were older, had a lower body mass index, longer diabetic duration, and had more hypertension, diabetic retinopathy, and smoking history than patients without diabetic foot.