Respiratory Muscle Overloading and Dyspnoea During Bronchoconstriction in Asthma: Protective Effects of Fenoterol

Whether, and to what extent, β₂-agonists protect against respiratory muscle overloading and breathlessness during bronchoconstriction remains to be defined in patients with asthma. In a double blind placebo-controlled study, 100 μg of fenoterol were administered to six stable asthmatics before a bronchial provocation test, performed by inhaling doubling concentrations of histamine from a Devilbiss 646 nebulizer. We recorded breathing pattern (tidal volume V_T, inspiratory time T_I, total time of the respiratory cycle T_TOT), inspiratory capacity (IC), dynamic pleural pressure swing (P_plsw), total lung resistance (R_L) and FEV₁. V_Twas expressed both in actual values and as % of IC. Changes in V_T(%IC) during histamine inhalation reflected changes in dynamic end-inspiratory lung volume (EILV). P_plswwas expressed as % of maximal (the most negative in sign) pleural pressure, obtained under control conditions during a sniff manoeuvre (P_plsn). P_plsw(%P_plsn) is an index of inspiratory muscle effort. The test ended when the concentration of histamine which caused a decrease in FEV₁of ≥40% post-saline was reached. Dyspnoea rating was scored by a modified Borg scale. At the ultimate degree of bronchoconstriction (UDB) with histamine: (i) decrease in FEV₁was similar after placebo and fenoterol, while increase in R_Lwas lower after fenoterol (P<0.005); (ii) V_T(%IC) increased less after fenoterol (P<0.027); (iii) increases in P_plsw(%P_plsn) was lower after fenoterol (P<0.001); (iv) ΔBorg (from saline) was lower (P<0.01) after fenoterol; (v) differences in ΔBorg, from placebo to fenoterol, related to concurrent changes in V_T(%IC) (r²=0.67). In conclusion, at UDB 100 μg of fenoterol produced a beneficial effect on the degree of inspiratory muscle loading and breathlessness, an effect greater than it would be expected from measuring FEV₁alone.     

Hypertrophic Cardiomyopathy : Present and Future,With Translation Into Contemporary Cardiovascular Medicine

Hypertrophic cardiomyopathy (HCM) is a common inherited heart disease with diverse phenotypic and genetic expression, clinical presentation, and natural history. HCM has been recognized for 55 years, but recently substantial advances in diagnosis and treatment options have evolved, as well as increased recognition of the disease in clinical practice. Nevertheless, most genetically and clinically affected individuals probably remain undiagnosed, largely free from disease-related complications, although HCM may progress along 1 or more of its major disease pathways (i.e., arrhythmic sudden death risk; progressive heart failure [HF] due to dynamic left ventricular [LV] outflow obstruction or due to systolic dysfunction in the absence of obstruction; or atrial fibrillation with risk of stroke). Effective treatments are available for each adverse HCM complication, including implantable cardioverter-defibrillators (ICDs) for sudden death prevention, heart transplantation for end-stage failure, surgical myectomy (or selectively, alcohol septal ablation) to alleviate HF symptoms by abolishing outflow obstruction, and catheter-based procedures to control atrial fibrillation. These and other strategies have now resulted in a low disease-related mortality rate of <1%/year. Therefore, HCM has emerged from an era of misunderstanding, stigma, and pessimism, experiencing vast changes in its clinical profile, and acquiring an effective and diverse management armamentarium. These advances have changed its natural history, with prevention of sudden death and reversal of HF, thereby restoring quality of life with extended (if not normal) longevity for most patients, and transforming HCM into a contemporary treatable cardiovascular disease.     

The Association between Cognitive Impairment and Diabetic Foot Care: Role of Neuropathy and Glycated Hemoglobin

Diabetes mellitus is associated with impairment in cognitive functions which can complicate adherence to self-care behaviors. We evaluated the incidence of cognitive impairment in patients with diabetes mellitus to determine the strength of the association between diabetic foot (a complication that occurs in about 10% of diabetic patients), adherence to the clinician’s recommendations, glycemic control, and cognitive function. A prospective study was carried out in a probabilistic sample of older patients with diabetic foot living in three nursing homes. Cognitive functions were evaluated by the MMSE (Mini-Mental State Examination), the Trail Making test (TMT), and the Michigan neuropathy screening instrument (MNSI). There were no significant associations between cognitive function and neuropathy or foot alterations, although glycated hemoglobin (HB1Ac > 7%) significantly (p < 0.05) associated with MMSE and adherence to treatment in the 1 month follow-up visit. Receiver operating characteristic curve analysis showed that both HB1Ac and the MNSI score significantly (p < 0.05) discriminate subsequent adherence to treatment for foot complication, with a sensitivity of 80.0–73.3% and specificity 70.6–64.7%, respectively. Proper control of foot complications in diabetic patients involves appropriate glycemic control and less severe neuropathy, and seems to be unrelated to cognitive dysfunction, and warrants further studies in order to tailor appropriate treatments to central and peripheral nervous system disorders. Poor glycemic control (Hb1Ac level > 7%) and a neuropathy score of 5.5 in the MNSI are the best-cut off points to discriminate poor adherence to the clinician’s recommendations for self-care behaviors in people with diabetic foot complication. In this study, we observed that foot disorders were associated with impaired global cognitive function in elderly patients (aged ≥ 65). Podiatrists and physicians should consider cognitive dysfunction as an important chronic complication in the management of diabetic foot.     

Pharmacological treatment of hypertrophic cardiomyopathy: current practice and novel perspectives

Hypertrophic cardiomyopathy (HCM) is entering a phase of intense translational research that holds promise for major advances in disease‐specific pharmacological therapy. For over 50 years, however, HCM has largely remained an orphan disease, and patients are still treated with old drugs developed for other conditions. While judicious use of the available armamentarium may control the clinical manifestations of HCM in most patients, specific experience is required in challenging situations, including deciding when not to treat. The present review revisits the time‐honoured therapies available for HCM, in a practical perspective reflecting real‐world scenarios. Specific agents are presented with doses, titration strategies, pros and cons. Peculiar HCM dilemmas such as treatment of dynamic outflow obstruction, heart failure caused by end‐stage progression and prevention of atrial fibrillation and ventricular arrhythmias are assessed. In the near future, the field of HCM drug therapy will rapidly expand, based on ongoing efforts. Approaches such as myocardial metabolic modulation, late sodium current inhibition and allosteric myosin inhibition have moved from pre‐clinical to clinical research, and reflect a surge of scientific as well as economic interest by academia and industry alike. These exciting developments, and their implications for future research, are discussed.     

Barbed versus traditional suture for enterotomy closure after laparoscopic right colectomy with intracorporeal mechanical anastomosis: a case–control study

Our aim was to establish the safety and efficacy of barbed suture for enterotomy closure after laparoscopic right colectomy with intracorporeal anastomosis. This study included 47 patients who underwent laparoscopic right hemicolectomy with intracorporeal mechanical anastomosis and barbed suture enterotomy closure (barbed suture closure—BSC) for adenocarcinoma (with the exception of T4 lesions and metastasis), compared with 47 matched patients who underwent laparoscopic right hemicolectomy with intracorporeal mechanical anastomosis and conventional suture enterotomy closure (conventional suture closure—CSC) during the same period. Controls were matched for stage, age, and gender via a statistically generated selection of all laparoscopic right hemicolectomies performed from January 2009 until December 2015. There was no difference between the two groups in terms of age, sex, BMI, ASA, co-morbidity, previous abdominal surgery, cancer site and cancer staging. In terms of operating time (median 120 min for BSC and 127.5 min for CSC), histopathological results, surgical site complications (2.1% for BSC and 8.5% for CSC), hospitalization (median 6 days for BSC and 5 days for CSC), readmission rate (0%), there were no differences between the groups (p > 0.05). No significant differences were noted between the two groups in terms of the postoperative course. Our results support that the use of knotless barbed sutures for enterotomy closure after laparoscopic right colectomy with intracorporeal mechanical anastomosis is safe and reproducible.