Geriatric nutritional risk index as the prognostic factor in older patients with fragility hip fractures.

This study investigated the long-term survival and incidence of secondary fractures after fragility hip fractures. The 5-year survival rate was 62%, and the mortality risk was seen in patients with GNRI < 92. The 5-year incidence of secondary fracture was 22%, which was significantly higher in patients with a BMI < 20. BACKGROUND: Malnutrition negatively influences the postoperative survival of patients with fragility hip fractures (FHFs); however, little is known about their association over the long term. OBJECTIVE: This study evaluated the ability of the geriatric nutritional risk index (GNRI) as a risk factor for long-term mortality after FHFs. METHODS: This study included 623 Japanese patients with FHFs over the age of 60 years. We prospectively collected data on admission and during hospitalization and assessed the patients' conditions after discharge through a questionnaire. We examined the long-term mortality and the incidence of secondary FHFs and assessed the prognostic factors. RESULTS: The mean observation period was 4.0 years (range 0-7 years). The average age at the time of admission was 82 years (range 60-101 years). The overall survival after FHFs (1 year, 91%; 5 years, 62%) and the incidence of secondary FHFs were high (1 year, 4%; 5 years, 22%). The multivariate Cox proportional hazard analysis revealed the risk factors for mortality as older age (hazard ratio [HR] 1.04), male sex (HR 1.96), lower GNRI score (HR 0.96), comorbidities (malignancy, HR 2.51; ischemic heart disease, HR 2.24; revised Hasegawa dementia scale ≤ 20, HR 1.64), no use of active vitamin D3 on admission (HR 0.46), and a lower Barthel index (BI) (on admission, HR 1.00; at discharge, HR 0.99). The GNRI scores were divided into four risk categories: major risk (GNRI, < 82), moderate risk (82-91), low risk (92-98), and no risk (> 98). Patients at major and moderate risks of GNRI had a significantly lower overall survival rate (p < 0.001). Lower body mass index (BMI) was also identified as a prognostic factor for secondary FHFs (HR 0.88 [p = 0.004]). CONCLUSIONS: We showed that older age, male sex, a lower GNRI score, comorbidities, and a lower BI are risk factors for mortality following FHFs. GNRI is a novel and simple predictor of long-term survival after FHFs.

Aspergillus fumigatus regulates mite allergen-pulsed dendritic cells in the development of asthma.

BACKGROUND: The role in allergic asthma development of the immune response against fungi with concomitant exposure to other common aeroallergens has yet to be determined. In particular, there is little understanding of how inhaled fungi affect the host response to mite allergens. OBJECTIVE: To characterize the in vitro and in vivo effects of concurrent exposure of Aspergillus fumigatus (Af) and Dermatophagoides farinae (Derf) on dendritic cells (DCs) in the development of allergic asthma. METHODS: Murine bone marrow-derived DCs were pulsed with Derf and/or live or heat-inactivated Af. Cytokine production and the expression of pathogen recognition receptors (PRRs) were determined in vitro. Subsequently, these DCs were inoculated into the airway of naïve mice to assess the development of allergic airway inflammation in vivo. The effect of antibodies against PRRs was also evaluated. RESULTS: Live Af significantly enhanced IL-10 production and the expression of Toll-like receptor (TLR) 2 and Dectin-1 in Derf-pulsed DCs. Live Af infection significantly attenuated Derf-pulsed DC-induced allergic airway inflammation in vivo. Antibodies against either TLR2 or Dectin-1 significantly reversed the inhibitory effects of live Af in the development of Derf-pulsed DC-induced allergic airway inflammation. CONCLUSION: Concurrent exposure of DCs to fungal antigens has profound influences on the subsequent mite allergen-induced allergic airway inflammation. Live Af could regulate the functions of airway DCs in the development of mite allergen-induced allergic airway inflammation via regulation of their PRRs. Our results suggest that concurrent exposure to pathogens such as fungi and mite allergens has profound influences on the subsequent allergen-induced allergic airway inflammation. Furthermore, modulating PRR signalling could provide a therapeutic regimen for the development of asthma.

Transplantation of the en bloc vascular system for coronary revascularization.

OBJECTIVES: Use of the free gastroepiploic artery graft for coronary revascularization has not been very popular because of its inclination toward vasospasm. We hypothesized that the cause of free gastroepiploic artery spasm was the graft damage caused by an interruption of venous drainage from the graft. To solve this problem, we developed a new method of free gastroepiploic artery grafting. METHODS: From January 1997 to October 1999, 33 patients underwent coronary artery bypass grafting with the free gastroepiploic artery according to our new method. The gastroepiploic artery graft was harvested en bloc with its satellite veins. The gastroepiploic vein was anastomosed to the right atrial appendage for venous drainage simultaneously with the gastroepiploic artery being grafted in the aortocoronary position. RESULTS: A total of 96 distal anastomoses were performed, including 33 free gastroepiploic artery grafts according to our method, 33 in situ left internal thoracic artery grafts, 26 saphenous vein grafts, and 4 radial artery grafts. Neither operative nor hospital death occurred. Early postoperative angiography revealed that all of the 33 free gastroepiploic artery grafts performed with our method were patent without spasm, and flow competition occurred only in 2 of those grafts. On late angiography, all 15 free gastroepiploic artery grafts were patent without spasm. CONCLUSIONS: The free gastroepiploic artery grafting with venous drainage technique we developed can prevent graft spasm, leading to improved patency rate.

Coronary artery bypass grafting for spontaneous coronary artery dissection: a case report and a review of the literature.

A 37 year-old woman underwent coronary angiography because of chest pain at rest. Selective coronary angiography demonstrated dissection and stenosis with a filling delay from the left main trunk to the left anterior descending coronary artery. The patient was successfully managed with urgent coronary artery bypass grafting. Spontaneous coronary artery dissection is relatively rare and threatens both elderly and young patients with acute coronary disturbances. Patients can be divided etiologically into three groups. The first was comprised of those in the postpartum period. The second was those with atherosclerotic coronary artery disease, and the third was those associated with coronary vasospasm. Dissections are frequently fatal and most of the known cases have been diagnosed at autopsy. Only a few cases have been documented by coronary angiography, and operative cases of spontaneous coronary artery dissection have rarely been reported.

Atrial flutter after coronary artery bypass grafting: proposed mechanism as illuminated by independent predictors.

OBJECTIVE: The aim of this study was to evaluate the cause and treatment of atrial flutter after coronary artery bypass grafting (CABG). METHODS: Between July 1999 and July 2000, 96 CABGs were performed at the Cardiovascular Center of Aichi Prefectural Owari Hospital. We compared two groups of patients: those with atrial flutter after CABG (group A) and those without atrial flutter (group B). RESULTS: We treated the atrial flutter group with medication, electrical defibrillation, and overdrive pacing. Six of these cases later required radiofrequency catheter ablation (RFCA). These were all with common-type atrial flutter, treated by RFCA for the posterior isthmus, without difficulty. The frequency of direct cannulation to the coronary sinus for retrograde cardioplegia was significantly higher in group A. CONCLUSIONS: Incidence of atrial flutter after CABG was influenced by surgical damage arising from direct cannulation to the coronary sinus for retrograde cardioplegia. Preoperative viability of the myocardium (in addition to good myocardial protection during surgery) also seems to be associated with an increased likelihood of postoperative atrial flutter.

[Coronary artery bypass grafting by warm blood cardioplegia and normothermic cardiopulmonary bypass].

Warm blood cardioplegia and normothermic cardiopulmonary bypass (CPB) have been used in coronary artery bypass grafting (CABG). The method of myocardial protection was intermittent combined antegrade and retrograde warm blood cardioplegia with terminal warm blood cardioplegia. We performed elective CABG in 30 patients above the age of 70 years (elderly group). These patients were compared with 30 patients below 70 years who underwent elective CABG (young group). No significant differences were observed about the preoperative data between two groups. No significant differences were obtained in the postoperative cardiac function, cerebral or renal complication between two groups. Warm blood cardioplegia and normothermic CPB were not associated with adverse effects on postoperative recovery in elderly as well as young patients. We may conclude that warm blood cardioplegia with normothermic CPB is a safe procedure for CABG in elderly as well as young patients.

[Repair of mitral valve prolapse by resection and sliding plasty].

There have been many techniques applied to the repair of mitral valve prolapse, and the method used in a particular case is usually selected according to the position and extent of the lesion. To simplify and standardize the technique of mitral valve repair, we have adopted the resection, sliding plasty and ring annuloplasty methods since December 1992. Of 10 consecutive surgical cases, 2 involved prolapse of the anterior leaflet, 1 the posteromedial commissural, and 7 the posterior leaflet. One patient with posterior leaflet prolapse required valve replacement due to dehiscence of the plastied site on the 3rd postoperative day, and one died because of sepsis. However, the remaining patients were doing well without mitral regurgitation at a mean of 20 months (range: 8-32) after the operation. The advantages of these techniques include easy adjustment of the height of the leaflet and a good chance of long-term durability, since the affected lesion is resected.

[Reoperation for complications of mitral valve surgery].

Among the early postoperative complications of mitral valve surgery. Mitral Regurgitation (MR) is one of the most dangerous complications, which has to be diagnosed and to be treated as early as possible. Four reoperations-two of which are of paraprosthetic regurgitation, and two of recurrent MR after mitral valve plasty-are reported. Their clinical courses and transesophageal echocardiographic findings are shown. And the differences their MR has when it is compared with the physiologic MR of the prosthetic valve and with the acceptable MR after mitral valve plasty are described.

[Valve replacement concomitant with anulus reconstruction].

It is important that surgical treatment of infective endocarditis involves complete debridement of the affected tissue. In case of abscess formation in the mitral anulus and/or aortic root, disruption of the anulus occurs because of radical resection of the abscess. David et al. reported a new technique for mitral and aortic anulus reconstruction. The novel part of the technique was the endocardial repair, i.e., suturing of a pericardial patch to the endocardium of the left ventricle. We were surprised to learn that the left ventricular endocardium and muscle are capable of tolerating the stress induced by the prosthetic ring, especially in the mitral position. Since 1992, we treated eight cases of anulus disruption using this technique ; 5 cases involved the mitral anulus, 1 involved the aortic, and 2 involved both. We used a slightly different technique involving suturing of a patch not only to the left ventricular endocardium but also to left atrial wall for reinforcement. Two patients died in the perioperative period. One had a brain abscess ; the other had methicillin-resistant Staphylococcus aureus sepsis and mediastinitis. There was 1 late (sudden, unknown) death 3 years after the operation. No perivalvular leakage, dehiscence of the patch, hemolysis, prosthetic valve endocarditis, or thromboembolism have been observed in the other 5 patients.

[Short-course chemotherapy of tuberculosis with pyrazinamide].

A 6-month regimen consisting of isoniazid (INH. 0.3-0.5 g).rifampicin (RFP. 0.3-0.45 g).pyrazinamide (PZA. 1.2-2.0 g) and streptomycin (SM. 0.75 g) or ethambutol (EB. 0.75-1.0 g) given for 2 month followed by isoniazid and rifampicin for 4 month is the preferred treatment for patients with fully susceptible organism, who adhere to treatment. Consideration should be given to treating all patients with directly observed treatment.

Effects of various anti-asthmatic agents on mite allergen-pulsed murine bone marrow-derived dendritic cells.

BACKGROUND: Dendritic cells (DCs) play an important role in the immune response and are critically involved in asthma. beta2-agonists could potentially exacerbate type 2 T helper (Th2) cell-mediated immune response. OBJECTIVES: To determine the effects of various anti-asthmatic agents on DCs function both in vitro and in vivo. METHODS: Murine bone marrow-derived DCs were pulsed with mite allergen in the presence of pranlukast, salbutamol, salmeterol or fluticasone. These DCs were then inoculated intranasally into naïve mice to induce allergic airway inflammation in vivo. RESULTS: Pranlukast reduced IL-10 and increased IL-12, while fluticasone reduced both IL-10 and IL-12 production by mite allergen-pulsed DCs. Allergic airway inflammation in pranlukast- and fluticasone-treated and mite allergen pulsed DCs-harbouring mice was attenuated and such response was associated with inhibition of Th2 response in the airway. Salbutamol did not alter cytokine production, while salmeterol reduced IL-12 production by mite allergen-pulsed DCs. Lung pathology in beta2-agonist-harbouring mice was comparable with those of mite allergen-pulsed DCs-harbouring mice. CONCLUSIONS: Our results indicate that leukotriene receptor antagonists and corticosteroids inhibit DCs-induced Th2 skewed immune response, and that short- and long-acting beta2-agonists do not modify DCs-induced allergic airway inflammation.

Hexamethylene diisocyanate causes contraction of canine tracheal smooth muscles through activation of muscarinic receptors.

BACKGROUND: Asthma caused by occupational exposure to hexamethylene diisocyanate (HDI) is well known; however, the exact pathogenic mechanisms remain unclear. METHODS: Experiments were performed using a standard canine tracheal smooth muscle (CTSM) strip preparation in an isolated bath to determine the effect of HDI on tracheal smooth muscle contraction. HDI concentration-response curves were constructed and the effects of different receptor antagonists on HDI-induced smooth muscle contraction were determined. To determine whether HDI and acetylcholine (ACh) bind to a common muscarinic receptor, ACh concentration-response curves in the absence or presence of HDI and concentration-response curves for HDI and ACh in the presence or absence of atropine were plotted. RESULTS: HDI caused contraction of CTSM, with a threshold concentration of 10(-7) M. The EC(50) (HDI concentration that produced 50% of the maximal response) was 6.2+/-0.7 x10(-7) M and the maximal contractile response (174+/-55 g/g of tissue) occurred at a concentration of 5.0+/-0.8 x 10(-6) M. Atropine, a muscarinic blocker, significantly inhibited HDI-induced contractile responses. HDI shifted the ACh concentration-response curve to the right. The mean pA(2) for atropine against ACh (8.93+/-0.27) was not significantly different from that against HDI (8.03+/-0.12). CONCLUSIONS: Our results indicated that HDI causes contraction of CTSM through the activation of muscarinic receptors. Direct stimulation of muscarinic receptors by HDI may play an important role in HDI-induced asthma.

Effects of amphotericin B gargles on oral colonization of Candida albicans in asthmatic patients on steroid inhalation therapy.

BACKGROUND: Early use of inhaled steroids is recommended for bronchial asthma. The side effects are rare, but oral discomfort and candidiasis are clinically important complications. Most previous studies reported that the use of spacer and water gargling was necessary to prevent oral complications. However, in some patients, this may fail to prevent such complications. OBJECTIVE: To compare the effects of water gargling with those of amphotericin B, in the prevention of oral complications in asthmatics using inhaled steroids. METHODS: Pharyngeal swab samples were obtained aseptically from the posterior pharyngeal wall of 128 asthmatics who have been using inhaled steroids (beclomethasone dipropionate) for more than 1 year. The amount of Candida albicans in cultured swabs was evaluated based on the following criteria: oral symptoms, method of gargling, dose of inhaled steroids, type of spacer and serum cortisol level. RESULTS: The number of isolated C. albicans was significantly higher in asthmatics with oral symptoms than in those free of symptoms. It was also significantly higher in patients who gargled with water or 1,000 times dilution than in those who gargled with 100 or 50 times dilutions of amphotericin B. Moreover, it was significantly higher in patients with low levels of serum cortisol than in those with normal serum cortisol. CONCLUSION: We demonstrated that at least in a subgroup of asthmatics using steroid inhalers, gargling with water or even weak concentrations of amphotericin B does not prevent colonization of the throat with C. albicans. This group at high risk of developing oral candidiasis should gargle with amphotericin B at concentrations higher than 100 times dilution that can prevent clinically detectable oral candidiasis.

Airway foreign body with clinical features mimicking bronchial asthma.

A 56-year-old Japanese male with persistent cough, stridor and diffuse wheezing for 6 months had obstructive pulmonary dysfunction and airway hyperresponsiveness (AHR) to inhaled methacholine. Because of a poor response to glucocorticoid therapy and neutrophilia in the peripheral blood and sputum, chest computed tomography was performed and a plate-like tumor in the truncus intermedius was identified. Fiberoptic bronchoscopy demonstrated a plate-like green-colored tumor firmly impacted into the truncus intermedius and diffuse inflammatory changes spreading to both main bronchi. A piece of 'kombu' (Japanese kelp) was successfully removed by fiberoptic bronchoscopy under general anesthesia. Pulmonary function and methacholine inhalation tests became normal after the removal of the foreign body. In this case, it is suggested that asthma-like symptoms were due to localized airflow limitation in the right bronchus as well as to AHR associated with diffuse airway neutrophilic inflammation.

Efficacy and safety of long-term treatment of asthmatic patients with pranlukast, a cysteinyl-leukotriene-receptor antagonist: four-year followup study.

BACKGROUND: There are few studies that have examined the long-term efficacy and safety of pranlukast, a leukotriene receptor antagonist, in asthmatic patients. METHODS: Sixty-three asthmatic patients were entered in this 4-year study [group 1, mild or moderate (N = 22); group 2, severe without using oral prednisolone (N = 22); group 3, severe with using oral prednisolone (N = 19)]. Pranlukast was administered at 225 mg twice daily to 14 subjects in group 1 (group 1p), 14 in group 2 (group 2p), and 11 in group 3 (group 3p), chosen for pranlukast additional therapy at random. Another group of 24 asthmatic patients was assigned to conventional therapy group (groups 1c, 2c, and 3c). Efficacy was determined by improvement in symptom score, peak expiratory flow rate (PEFR) percentage predicted, reduced daily variability of PEFR (percentage), and reduced frequency of use of rescue beta2-agonist (times per week). RESULTS: In groups 1p and 2p, PEFR percentage predicted began to improve from 2 weeks after commencement of treatment. The symptom score, daily variability of PEFR, and use of rescue beta2-agonist diminished significantly. In group 3p, pranlukast was ineffective in improving PEFR percentage predicted. All but two patients continued to receive pranlukast and no adverse effects were noted, at least during the 16-week therapy. Further, 22 patients continued to receive pranlukast for 4 years, and none experienced any adverse effects. CONCLUSIONS: We showed in this study that long-term treatment with pranlukast is effective for asthmatic patients without any adverse effects.

Effects of pranlukast on aspirin-induced bronchoconstriction: differences in chemical mediators between aspirin-intolerant and tolerant asthmatic patients.

BACKGROUND: Aspirin inhibits cyclooxygenase activity and modifies production of the arachidonate cascade in aspirin-induced asthma. The aim of the present study was to examine the effects of leukotriene (LT) receptor antagonist on aspirin challenge on eosinophil activity and chemical mediators released into the airway of asthmatic patients. METHODS: Aspirin oral provocation test was performed in aspirin-intolerant asthmatic patients (AIA; N = 7) and aspirin-tolerant asthmatic patients (ATA; N = 7). In AIA, LT receptor antagonist (pranlukast) was administered orally 2 hours before the test, and its inhibitory effects on sputum LTC4+C4, eosinophil cationic protein (ECP), eosinophil count, urinary LTE4/creatinine (Cr), 11-dehydrothromboxane (11-dhTX) B2/Cr, serum LTC4+D4, ECP, and peripheral blood eosinophil count were compared with the findings in ATA subjects. RESULTS: In AIA, aspirin induced an immediate reaction associated with increased urinary LTE4/Cr and sputum ECP and a fall in urinary 11-dhTXB2/Cr. Pranlukast inhibited the bronchial reaction and an increase in sputum ECP after threshold dosed of ASA, but failed to change aspirin-induced LT production in sputum and urine. In ATA, aspirin challenge was only associated with a fall in urinary 11-dhTXB2. CONCLUSIONS: Our results indicated that aspirin-induced asthma is associated with overproduction of LT with a shift to the 5-lipoxygenase series of the arachidonate cascade and that leukotriene receptor antagonist are useful for AIA through inhibition of production of LT and eosinophilic inflammation in the airway.

Effects of pranlukast, a cysteinyl leukotriene receptor 1 antagonist, combined with inhaled beclomethasone in patients with moderate or severe asthma.

BACKGROUND: Although inhaled steroids are used as the first line of therapy in asthmatic patients, symptoms of asthma do not improve completely in some patients. OBJECTIVE: To investigate the effects of pranlukast, a cysteinyl leukotriene receptor 1 antagonist, in patients with moderate/severe asthma, when combined with beclomethasone dipropionate (BDP). METHODS: Protocol 1: After a 2-week observation period, 41 patients with moderate asthma were divided into those receiving BDP at 1,600 microg/day or 800 microg/day + pranlukast (450 mg/day). The effect of treatment was evaluated by measuring AM peak expiratory flow rate, symptom score, frequency of beta2-agonists, and daily variability of peak expiratory flow rate. Protocol 2: 39 patients participated in this study including those with moderate asthma on 800 microg/day BDP (group I), severe asthma on BDP at 1,600 microg/day (group II), and severe asthma on 1,600 microg/day BDP + 5 to 20 mg prednisolone (group III). Patients of all groups were additionally treated with pranlukast. RESULTS: Protocol 1: Both treatment regimens resulted in improvement in each clinical parameter. There were no significant differences in the effects of two treatment regimens. Protocol 2: Pranlukast was effective in group I and II, but not in group III. In groups I and II, pranlukast tended to be more effective when BDP was introduced within the first year of onset of asthma. CONCLUSIONS: Pranlukast is effective for patients with moderate asthma and those patients with severe asthma who are not treated with oral steroids. Pranlukast is more effective in patients treated with BDP early after onset.

Bronchial hyperresponsiveness and airway inflammation in adolescents with asymptomatic childhood asthma.

BACKGROUND: About 70% of childhood asthmatics become free of asthma-related symptoms during adolescence. Little is known about bronchial hyperresponsiveness (BHR) and airway inflammation in young adults with "outgrown" childhood asthma. METHODS: We studied 61 nonsmoking medical students (18 intermittent mild asthmatics, 23 students with outgrown childhood asthma but free of asthma-related symptoms for 10 years (asymptomatic asthmatics) and 20 healthy students). BHR and lung function were measured, and induced sputum samples analyzed for eosinophil count, eosinophilic cationic protein (ECP), granulocyte-macrophage colony stimulating factor (GM-CSF), and tumor necrosis factor-alpha (TNF-alpha). RESULTS: BHR was still present in most asymptomatic asthmatics, but it was milder compared with healthy students. Only three subjects with previous asthma had no BHR and no signs of airway inflammation. Percentages of eosinophil, and ECP, TNF-alpha and GM-CSF concentrations in induced sputum of mild asthmatics and asymptomatic asthma groups were higher than in the healthy group. In asymptomatic asthmatics group, the duration of asthma, sputum eosinophil percentage, and the level of TNF-alpha in sputum correlated significantly with BHR. CONCLUSIONS: Only a few subjects with longstanding asymptomatic asthma could be considered as cured; most asymptomatic asthmatics continued to exhibit BHR and signs of airway inflammation. The outcome of childhood asthma and BHR was associated with the degree of airway inflammation and the duration of childhood asthma.

Pranlukast, a cysteinyl leukotriene receptor 1 antagonist, attenuates allergen-specific tumour necrosis factor alpha production and nuclear factor kappa B nuclear translocation in peripheral blood monocytes from atopic asthmatics.

BACKGROUND: The cysteinyl leukotriene receptor 1 (cysLTR1) antagonists are useful for oral treatment of bronchial asthma. The underlying mechanism of cysLTR1 antagonists on inhibition of inflammatory cytokine production is yet to be determined. OBJECTIVE: The present study was designed to determine the effect of pranlukast, a cysLTR1 antagonist, on production of inflammatory cytokines by allergen-stimulated peripheral blood monocytes (PBM) from atopic asthmatics. METHODS: PBM were obtained from normal control (n = 10) and Dermatophagoides farinae (Der f) allergen-sensitized atopic asthmatics (n = 12), and were cultured in the presence of Der f allergen. The production of TNF-alpha and nuclear-translocation of nuclear factor kappa B (NF-kappa B) was determined. In atopic asthmatics, pranlukast, tacrolimus or dexamethasone was added before stimulation by Der f. The additive effect of pranlukast and dexamethasone was also determined. RESULTS: PBM from atopic asthmatics cultured with Der f exhibited a significant increase in TNF-alpha production and nuclear translocation of NF-kappa B compared with normal control (P < 0.01). Pranlukast, tacrolimus and dexamethasone significantly inhibited production of TNF-alpha and nuclear-translocation of NF-kappa B in PBM of atopic asthmatics (P < 0.01). An additive effect of pranlukast on low-dose dexamethasone was also demonstrated. However, LTD4 did not induce TNF-alpha production or NF-kappa B nuclear translocation. CONCLUSION: Our results suggest that pranlukast may inhibit TNF-alpha production via suppression of NF-kappa B activation through pathways distinct from cysLTR1 antagonism.