Multiple logistic regression analysis of risk factors for the development of steroid-dependent asthma in the elderly: a comparison with younger asthmatics

BACKGROUND: The percentage of the aged among all patients with bronchial asthma is increasing. OBJECTIVE: To investigate the risk factors for the development of steroid-dependent asthma in the elderly. METHODS: A multiple logistic regression analysis involving various clinical factors between steroid-dependent and -independent asthma was carried out for 59 asthmatics aged over 60 years, including 16 patients with steroid-dependent asthma. The calculated risk for each factor was compared with that obtained from 122 younger asthmatics aged 20-59 years. RESULTS: Among the factors examined (sex, age, period from onset of asthma, type of asthma and family history of asthma, plus history of smoking, atopic dermatitis, allergic rhinitis, chronic sinusitis and nasal polyps), the significant risk factors for the development of steroid dependency in the elderly asthmatics were only family history of bronchial asthma (relative risk 3.6) and smoking history (relative risk 6.9). CONCLUSIONS: Some risk factors for steroid-dependent asthma in younger individuals were not significant in the elderly. Since the smoking history was most closely associated with the development of steroid dependency in the elderly, even though most of them had quit smoking, it is important for patients with asthma to avoid smoking.     

Clinical effects of long-term administration of pimobendan in patients with moderate congestive heart failure

Summary The long-term efficacy of the positive inotropic and vasodilator drug, pimobendan, was assessed in 21 patients suffering from symptomatic heart failure. Patients were randomized to 16 weeks of double-blind therapy with either 2.5 or 5.0mg/day of pimobendan (n = 10), or a matching placebo (n = 11). Patients were blinded on the study drug if their clinical status had not substantially worsened during the study. Of the placebo-treated patients, 5 patients were withdrawn from the study because of a deterioration of their heart failure, while none of the active treated group was withdrawn because of increased symptoms. Quality of life, assessed by the specific activity scale derived from the metabolic costs of individual physical activity, was 3.45 ± 0.90 (SD) mets in the baseline state and increased significantly after week 16, averaging 5.07 ± 1.40 and 4.67 ± 1.47 mets at weeks 16 and 24, respectively. In the placebo-treated group, the specific activity scale was 3.27 ± 1.21 mets at the baseline and remained unchanged throughout the study period. Patients treated with pimobendan were able to significantly increase their exercise duration. The accompanying increase in peak oxygen uptake was statistically insignificant, due to the limited number of patients enrolled in the study. These results suggest that in contrast to the recent pessimistic view of the long-term efficacy of cardiotonic drugs, pimobendan is beneficial in treating patients with congestive heart failure and may favorably modify their prognosis. Further largescale evaluation of this agent is warranted.     

Cystic dilatation of peribiliary glands in livers with adult polycystic disease and livers with solitary nonparasitic cysts: an autopsy study.

Cystic dilatation of peribiliary glands of intrahepatic and extrahepatic bile ducts was investigated in autopsied livers with adult polycystic disease (n = 8), in autopsied livers with solitary nonparasitic cysts (n = 18) and in normal autopsied livers (n = 23). In normal livers, cystic dilatation of intrahepatic peribiliary glands was absent or slight, when present. In livers with solitary nonparasitic cysts, cystic dilatation of intrahepatic peribiliary glands was present in varying degrees. In livers with adult polycystic disease, intrahepatic peribiliary glands showed frequent and severe cystic dilatation so marked that it was grossly recognizable. In contrast, peribiliary glands of the extrahepatic bile ducts showed no cystic dilatation in most cases, regardless of the three conditions examined. Liver parenchymal cysts were numerous in livers with adult polycystic disease, few in livers with solitary nonparasitic cysts and nonexistent in normal livers. Von Meyenburg complexes were present in 87.5% of livers with adult polycystic disease, in 16.7% of livers with solitary nonparasitic cysts and in 4.3% of normal livers. These findings suggest that intrahepatic peribiliary glands undergo cystic dilatation in livers with adult polycystic disease-and, to a lesser degree and frequency in livers with solitary nonparasitic cysts, probably because of congenital or genetic factors-and that these cystic changes may comprise a part of numerous cysts of adult polycystic disease.     

Selective necrosis of encapsulated malignant lesion within atypical adenomatous hyperplasia of the liver following transarterial embolization. A report of two autopsy cases.

We report here the morphology of two nodules of atypical adenomatous hyperplasia (AH), a preneoplastic or early developmental stage of hepatocellular carcinoma (HCC), with a fibrously encapsulated malignant lesion occurring in two cirrhotic livers. The two patients had been treated for HCC by transarterial embolization. At autopsy, HCC nodules and several AH nodules were found in each case. Microscopically, two of the several AH nodules contained malignant lesions that showed selective coagulative necrosis: the hepatocytes of the nonmalignant parts of the two AH nodules were viable. The malignant lesions within the atypical AH nodules were surrounded with a fibrous capsule, and the majority of HCC nodules were necrotic; AH nodules themselves, except for malignant lesions, were viable. This suggests to us that there are differences in blood supply between the malignant lesions and surrounding tissue of atypical AH: malignant lesions within atypical AH may be supplied mainly by arterial blood, whereas nonmalignant areas of atypical AH may be dually supplied by both arterial and portal blood. Alternatively, it may be that the malignant lesions in atypical AH are more susceptible to hypoxia caused by transarterial embolization.     

Relation of QT-interval variability to ventricular arrhythmias during percutaneous transluminal coronary angioplasty

The present study investigated the role of the dispersion of QT interval in percutaneous transluminal coronary angioplasty (PTCA)-induced ventricular tachyarrhythmias. Patients with effort angina without a previous myocardial infarction (n = 22), who had single-vessel disease of the anterior descending coronary artery (LAD), underwent PTCA if the coronary lesion was 75% or more stenosed in segment 6 or 7 of the LAD. The standard 12-lead ECG was continuously recorded during the procedure. Averaged QTc and QTac intervals, where QTac was the interval from the beginning of QRS complex to the nadir of T wave corrected by Bazett's formula, did not change significantly during PTCA. Of the 22 patients, 7 showed ventricular arrhythmias during PTCA. The maximum difference (deltaQTc) and the standard deviation (QTcSD) of the corrected QT interval in the standard 12-lead ECG increased significantly during PTCA in the 7 patients with ventricular arrhythmias, whereas they decrreased in the 15 patients without ventricular arrhythmias. deltaQTac and QTacSD were not affected by PTCA regardless of ventricular arrhythmias, which shows that the increases in the variation of the ventricular repolarization process play a role in PTCA-induced ventricular arrhythmias.     

Superior vena cava syndrome after bone marrow transplantation caused by aspergillosis: a case report

Aspergillosis is known for the variety of unusual presentations in immuno-suppressed patients. We report a patient in whom aspergillosis caused the superior vena cava (SVC) syndrome. A 37-year-old woman became febrile soon after bone marrow transplantation (BMT). Chest radiography demonstrated a 5-cm mass extending from the right lung apex to the right supraclavicular fossa beside her Hickman catheter. She then developed SVC syndrome, which progressed despite treatment. Despite recovery of the white blood cell count, the patient continued to deteriorate, became comatose, suffered a cardiac arrest and died 31 days after BMT. Autopsy revealed Aspergillus infection at the apex of the right lung associated with innominate artery thrombosis.     

Evidence for Reactivation of Human Herpesvirus 6 in Generalized Lymphadenopathy in a Patient with Drug-Induced Hypersensitivity Syndrome

The present case provides direct evidence of human herpesvirus 6 reactivation in resected lymph node tissue in a patient with drug-induced hypersensitivity syndrome. This case clearly demonstrates that appropriate pathological evaluation of lymphadenopathy for drug-induced hypersensitivity syndrome, which mimics malignant lymphoma in clinical, radiological, and pathological findings, is required.     

Therapeutic Interventions for Increasing Ankle Dorsiflexion After Ankle Sprain: A Systematic Review

Context:

Clinicians perform therapeutic interventions, such as stretching, manual therapy, electrotherapy, ultrasound, and exercises, to increase ankle dorsiflexion. However, authors of previous studies have not determined which intervention or combination of interventions is most effective.

Objective:

To determine the magnitude of therapeutic intervention effects on and the most effective therapeutic interventions for restoring normal ankle dorsiflexion after ankle sprain.

Data Sources:

We performed a comprehensive literature search in Web of Science and EBSCO HOST from 1965 to May 29, 2011, with 19 search terms related to ankle sprain, dorsiflexion, and intervention and by cross-referencing pertinent articles.

Study Selection:

Eligible studies had to be written in English and include the means and standard deviations of both pretreatment and posttreatment in patients with acute, subacute, or chronic ankle sprains. Outcomes of interest included various joint mobilizations, stretching, local vibration, hyperbaric oxygen therapy, electrical stimulation, and mental-relaxation interventions.

Data Extraction:

We extracted data on dorsiflexion improvements among various therapeutic applications by calculating Cohen d effect sizes with associated 95% confidence intervals (CIs) and evaluated the methodologic quality using the Physiotherapy Evidence Database (PEDro) scale.

Data Synthesis:

In total, 9 studies (PEDro score = 5.22 ± 1.92) met the inclusion criteria. Static-stretching interventions with a home exercise program had the strongest effects on increasing dorsiflexion in patients 2 weeks after acute ankle sprains (Cohen d = 1.06; 95% CI = 0.12, 2.42). The range of effect sizes for movement with mobilization on ankle dorsiflexion among individuals with recurrent ankle sprains was small (Cohen d range = 0.14 to 0.39).

Conclusions:

Static-stretching intervention as a part of standardized care yielded the strongest effects on dorsiflexion after acute ankle sprains. The existing evidence suggests that clinicians need to consider what may be the limiting factor of ankle dorsiflexion to select the most appropriate treatments and interventions. Investigators should examine the relationship between improvements in dorsiflexion and patient progress using measures of patient self-reported functional outcome after therapeutic interventions to determine the most appropriate forms of therapeutic interventions to address ankle-dorsiflexion limitation.Key Words: chronic ankle instability, range of motion, stretching, joint mobilization

Key Points

• A static-stretching intervention as part of a standardized home exercise program had the strongest effects on ankle-dorsiflexion improvement after acute ankle sprains.
• Clinicians need to consider what may be the limiting factor of ankle dorsiflexion to select the most appropriate treatments and interventions.
• Investigators should examine the long-term effects of treatments on ankle dorsiflexion and a relationship between an improvement in ankle dorsiflexion and measures of patient self-reported and physical function to determine the most appropriate forms of therapeutic interventions to address limited dorsiflexion.

Lateral ankle sprain has been documented to be the most common lower extremity injury sustained during sport participation.^1–4 Approximately 85% of all ankle sprains result from an inversion mechanism and damage to the lateral ligamentous complex of the ankle.⁵ Injury to the lateral ligamentous complex at the ankle joint results in pain, swelling, and limited osteokinematics.⁶ A loss of normal ankle dorsiflexion usually is observed at the talocrural joint after lateral ankle sprain.^7–12The amount of available ankle dorsiflexion plays a key role in the cause of lower extremity injuries.^7,13–22 Limitation of dorsiflexion may be a predisposition to reinjury of the ankle^11,16 and several future lower limb injuries, including plantar fasciopathy,^13,20,21 lateral ankle sprains,^13,15,17,19 iliotibial band syndrome,¹⁴ patellofemoral pain syndrome,¹⁸ patellar tendinopathy,²² and medial tibial stress syndrome.¹⁴The importance of restoring ankle dorsiflexion after an acute ankle sprain often is emphasized in rehabilitation guidelines,⁹ and proper recovery of ankle dorsiflexion is a vital component of ankle rehabilitation. Inadequate restoration of ankle dorsiflexion may increase the risk of developing recurrent ankle sprain^11,16 and limit functional activities, such as walking, with long-term pain and disability.²³ Limited ankle-dorsiflexion range of motion (ROM) after lateral ankle sprain has been considered a predisposing factor for recurrent ankle sprain because diminished dorsiflexion prevents the ankle from reaching its closed-pack position by holding the ankle in a hypersupinated position. Therefore, ensuring appropriate restoration of ankle dorsiflexion after ankle sprain has important clinical implications for restoring full functional abilities, ultimately leading to reduced risk of recurrent ankle sprain.Clinicians perform several therapeutic interventions, such as stretching, manual therapy, electrotherapy, ultrasound, and exercises, to increase ankle dorsiflexion. However, the intervention or combination of interventions that most effectively improves ankle dorsiflexion has not been established. In previous systematic reviews,^24–26 researchers have examined the effects of specific intervention techniques of manipulative therapy on various outcome variables. In addition, Bleakley et al²⁷ conducted a systematic review with a comprehensive search of various therapeutic interventions to provide evidence for the management of ankle sprains and the prevention of long-term complications; however, the authors focused only on patients with an acute ankle sprain. Therefore, the purpose of this systematic review was to determine the magnitude of therapeutic intervention effects on and the most effective therapeutic interventions for restoring normal ankle dorsiflexion after ankle sprain. In contrast to previous reviews,^24–26 we comprehensively searched the existing literature to determine the effectiveness of various therapeutic intervention techniques in restoring ankle dorsiflexion in patients with acute, subacute, or recurrent ankle sprains. By providing a quantitative estimate of the magnitude of the effect of therapeutic interventions, our review provides a new perspective on the evidence of interventions to restore ankle dorsiflexion in various stages of ankle-sprain conditions.     

Primary small cell carcinoma of prostate without immunoreactive neuroendocrine proteins but with expressions of KIT and platelet‐derived growth factor‐α

Primary small cell carcinoma of the prostate is extremely rare. Herein reported is a case of primary small cell carcinoma of the prostate with immunohistochemical examination of KIT and platelet‐derived growth factor‐α. The present case is unique in that the small cell carcinoma did not express neuroendocrine antigens. A 68‐year‐old man was found to have high serum prostate‐specific antigen, and biopsy showed malignant small tumor cells fulfilling the small cell carcinoma criteria of the World Health Organization. Immunohistochemically, tumor cells were positive for pan‐cytokeratin, KIT, platelet‐derived growth factor‐α, p53, Ki‐67 labeling = 65%, prostate‐specific antigen and alpha‐methylacyl‐CoA racemase. Tumor cells were negative for vimentin, CD56, synaptophysin, chromogranin and neuron‐specific enolase. Imaging modalities showed multiple metastases, and the patient was treated by chemotherapy. The present report is the fifth with immunohistochemistry of prostatic small cell carcinoma.