The neurologist's dilemma: a comprehensive clinical review of Bell's palsy, with emphasis on current management trends.

BACKGROUND: Recent advances in Bell's palsy (BP) were reviewed to assess the current trends in its management and prognosis. MATERIAL/METHODS: We retrieved the literature on BP using the Cochrane Database of Systematic Reviews, PubMed, and Google Scholar. Key words and phrases used during the search included 'Bell's palsy', 'Bell's phenomenon', 'facial palsy', and 'idiopathic facial paralysis'. Emphasis was placed on articles and randomized controlled trails (RCTs) published within the last 5 years. RESULTS: BP is currently considered the leading disorder affecting the facial nerve. The literature is replete with theories of its etiology, but the reactivation of herpes simplex virus isoform 1 (HSV-1) and/or herpes zoster virus (HZV) from the geniculate ganglia is now the most strongly suspected cause. Despite the advancements in neuroimaging techniques, the diagnosis of BP remains one of exclusion. In addition, most patients with BP recover spontaneously within 3 weeks. CONCLUSIONS: Corticosteroids are currently the drug of choice when medical therapy is needed. Antivirals, in contrast, are not superior to placebo according to most reliable studies. At the time of publication, there is no consensus as to the benefit of acupuncture or surgical decompression of the facial nerve. Long-term therapeutic agents and adjuvant medications for BP are necessary due to recurrence and intractable cases. In the future, large RCTs will be required to determine whether BP is associated with an increased risk of stroke.

Glucocorticoid analogues: potential therapeutic alternatives for treating inflammatory muscle diseases.

Glucocorticoids (GCs) have been prescribed to treat a variety of diseases, including inflammatory myopathies and Duchenne muscular dystrophy for over 50 years. However, their prescription remains controversial due to the significant side effects associated with the chronic treatment. It is a common belief that the clinical efficacy of GCs is due to their transrepression of pro-inflammatory genes through inhibition of inflammatory transcription factors (i.e. NF-κB, AP-1) whereas the adverse side effects are attributed to the glucocorticoid receptor (GR)-mediated transcription of target genes (transactivation). The past decade has seen an increased interest in the development of GR modulators that maintain the effective anti-inflammatory properties but lack the GR-dependent transcriptional response as a safe alternative to traditional GCs. Many of these analogues or "dissociative" compounds show potential promise in in vitro studies but fail to reach human clinical trials. In this review, we discuss molecular effects of currently prescribed GCs on skeletal muscle and also discuss the current state of development of GC analogues as alternative therapeutics for inflammatory muscle diseases.

Unawareness and undertreatment of asthma: follow-up in a different geographic area in Denmark.

BACKGROUND: Early detection and treatment of asthma is important to minimize morbidity and healthcare costs. The objective of this study was to investigate asthma awareness and management in a western society. METHODS: In a random sample of 10 400 subjects aged 14-44 years, 686 (6.6%) reported symptoms of asthma in a standardized screening questionnaire. All 686 were evaluated by respiratory specialists and diagnosed by history, symptoms, lung function tests, bronchial challenges and allergy testing. Of these 686 participants, 69 (10%) had asthma alone, 205 (30%) had rhinitis alone and 217 (32%) had both asthma and rhinitis; 195 (28%) had nonasthmatic respiratory reports. RESULTS: Awareness of asthma was found among 163 (57%) of the 286 asthmatics, and 204 (95%) had doctor-diagnosed rhinitis as well. In a multivariate regression analysis, comorbidity with rhinitis (beta = 0.489, P < 0.001), smoking (beta = -0.116, P < 0.01), doctor-diagnosed bronchitis (beta = 0.086, P < 0.05), and earlier emergency visits at hospital (beta = 0.147, P < 0.001) was significantly associated with awareness. A difference in awareness was found between those who had asthma and rhinitis (62.2%) and those who had asthma alone (40.6%) (P < 0.01). Inhaled corticosteroids (ICS) were used by 27% of those with asthma, including 12% who used both ICS and long-acting beta-agonist. CONCLUSIONS: More than half of the persons with asthma were aware of their disorder; and the awareness was more likely in those with comorbidity of rhinitis. In general, asthma management was inadequate.

Antidepressant-like effects of the glucocorticoid receptor antagonist RU-43044 are associated with changes in prefrontal dopamine in mouse models of depression.

Chronic corticosterone and isolation rearing paradigms may provide reliable mouse models of depression. Using these models, the present study examined if the specific glucocorticoid receptor antagonist, RU-43044, has an antidepressant-like effect, and studied the possible role of prefrontal neurotransmission on the behavioral effects. Chronic administration of corticosterone and isolation rearing increased the immobility time in the forced swim and tail suspension tests. Subchronic treatment with RU-43044 decreased the immobility time in the forced swim test in chronic corticosterone-treated and isolation-reared mice, but not the control mice. Chronic corticosterone decreased the levels of cortical glucocorticoid receptors and stress-induced increases in plasma corticosterone levels, and blocked the response of plasma corticosterone to dexamethasone, while isolation rearing did not cause any changes in the glucocorticoid receptor system. Both chronic corticosterone and isolation rearing markedly increased high K+ -induced dopamine release, but not serotonin release, in the prefrontal cortex. Subchronic RU-43044 reversed the enhanced release of dopamine in the prefrontal cortex of chronic corticosterone-treated and isolation-reared mice. These results suggest that chronic corticosterone and isolation rearing increase the depressive-like behavior in glucocorticoid receptor-dependent and independent manners, respectively, and that RU-43044 shows an antidepressant-like effect, probably via an inhibition of enhanced prefrontal dopaminergic neurotransmission in these mouse models.

Risk factors leading to hospital admission in Iranian asthmatic children.

BACKGROUND: Asthma is one of the most common chronic diseases in the world, leading to an increased rate of hospitalization. We performed this study to better understand the factors leading to admission among asthmatic children. METHODS: We performed a study among asthmatic children in a referral hospital for asthma and allergy in Tehran. Sixty-three cases were selected from asthmatic children admitted to the emergency room (ER) who still had an indication for ward or intensive care unit admission after primary treatment. Our control group was the asthmatic children discharged after primary treatment and patients who were referred to the asthma and allergy clinic (63 patients). Data were obtained by structured questionnaires filled out during clinical interviews. RESULTS: There was a significant difference in mean age (5 years for cases vs. 6 years for controls; p = 0.049), personal and familial allergic history (69.8 and 57.1% for cases vs. 34.9 and 36.5% for controls; p < 0.01 and p = 0.02, respectively), history of recent respiratory infections (79.4% for cases vs. 49.2% for controls; p < 0.01), hospitalization history due to asthma (57.1% for cases vs. 23.8% for controls; p < 0.01) and regular use of inhaled corticosteroid (66.7% for cases vs. 33.3% for controls; p < 0.01). CONCLUSIONS: Our findings confirm most previous observations, suggesting that recent respiratory infections, hospitalization, personal or familial allergy, disease severity and lower ages are important factors leading to hospitalization. We also found that regular clinical follow-up, regular use of inhaled corticosteroids, higher IgE levels and O2 saturation may lower the probability of hospitalization during asthmatic attacks.

[Autoimmune pancreatitis].

The paper presents the currently available data on the epidemiology, pathogenesis, and clinical features of autoimmune pancreatitis, as well as the capacities and markers of its morphological, laboratory, and radiation diagnosis. Autoimmune pancreatitis is a special type of chronic pancreatitis in which autoimmune mechanisms are the most important and leading link of pathogenesis. The specific features of treatment for this condition are mentioned. These are the use of corticosteroid hormones without surgery.

Patient and physician perspectives on the attributes of nasal allergy medications.

Allergic rhinitis (AR) often requires regular prophylactic use of allergy medications for the effective long-term management of nasal symptoms. However, patient adherence to AR treatment is frequently poor. The Allergies in America survey of nasal allergy sufferers assessed 2500 adults diagnosed with AR. Four hundred healthcare professionals also participated in this survey. Participants were interviewed about their perceptions of the effectiveness and tolerability of AR medications and the relationship of these parameters to patient satisfaction with therapy. Only 15% of nasal allergy sufferers reported that their intranasal corticosteroid (INCS) provided complete symptom relief, and 48% of patients indicated that their INCS did not provide 24-hour symptom relief. Healthcare professionals agreed that intranasal corticosteroids do not provide complete 24-hour symptom relief. The most commonly reported adverse effects of all nasal allergy medications were a drying feeling (47%), dripping down the throat (41%), drowsiness (37%), bad taste (32%), burning (17%), and headaches (16%). Many patients indicated that these adverse effects were moderately or extremely bothersome. Thirty-two percent and 25% of patients, respectively, discontinued treatment because their nasal allergy medications did not provide 24-hour symptom relief or were associated with bothersome adverse effects. Patients and healthcare professionals do not believe that INCSs provide complete 24-hour symptom relief. In general, allergy medications also are perceived as conferring unpleasant adverse effects. Lack of efficacy and bothersome adverse effects contribute to lack of satisfaction with treatment and treatment discontinuation in patients with AR.

Primary bacteraemia caused by Rhizobium radiobacter in a patient with solid tumours.

A case of Rhizobium radiobacter primary bacteraemia in a patient with solid tumours is reported. Corticosteroid therapy and diabetes mellitus were the predisposing factors. The patient was treated successfully with amikacin and piperacillin/tazobactam. The clinical isolate was identified as R. radiobacter by 16S rRNA gene sequencing. Phytopathogenicity tests and a PCR assay demonstrated that the organism was not a plant pathogen.

Use of voriconazole in a patient with aspergilloma caused by an itraconazole-resistant strain of Aspergillus fumigatus.

The case is reported of a patient with cavitary sarcoidosis complicated by an aspergilloma caused by an itraconazole-resistant strain of Aspergillus fumigatus, who was treated with voriconazole. The authors suggest that susceptibility testing of A. fumigatus strains is of value during long-term therapy with itraconazole, and that voriconazole may be a good option for treatment of patients infected with itraconazole-resistant strains of A. fumigatus.

The blocking effect of essential controller medications during aspirin challenges in patients with aspirin-exacerbated respiratory disease.

BACKGROUND: The blocking effect of controller medications for asthma could have an effect on the outcome of aspirin challenges in patients suspected of having aspirin-exacerbated respiratory disease (AERD). OBJECTIVE: To evaluate whether there was any blocking effect of long-acting beta2-agonists, systemic corticosteroids, and/or inhaled corticosteroids alone or as co-therapy with leukotriene modifier drugs (LTMDs). METHODS: Between 1981 and 2004, 678 patients with suspected AERD were admitted for aspirin challenge and desensitization. All patients had asthma, chronic sinusitis, nasal polyposis, and at least 1 historical reaction to a nonsteroidal anti-inflammatory drug. Asthma controller medications taken during aspirin challenge were recorded and analyzed with respect to their potential effects on 4 possible outcomes of aspirin challenge, namely, naso-ocular reaction, lower airway reaction, classic upper and lower airway reaction, or a negative challenge result. RESULTS: When compared with AERD patients who received no controller medications, the combined use of LTMDs, inhaled corticosteroids, and long-acting beta2-agonists led to a statistically significant change in aspirin challenge outcomes (P = .009), mainly shifting the reaction from a classic upper and lower respiratory tract reaction to naso-ocular reactions only. LTMDs appeared to have the strongest effect (P < .001) in blocking lower respiratory tract reactions. Systemic corticosteroids did not have the same effects. Blocking of both upper and lower respiratory tract reactions to aspirin as a result of taking controller medications did not occur. CONCLUSION: Controller medications are frequently needed to stabilize airways of patients with AERD. LTMDs alone or in combination with other controllers blocked lower respiratory tract reactions during aspirin challenge in some patients with AERD but did not change the overall rate of positive aspirin challenge results and did not lead to false-negative challenges.

Intradural extramedullary tuberculoma of the spinal cord: a review of reported cases.

Intradural extramedullary tuberculoma of the spinal cord (IETSC) is a rare modality of tuberculosis, with only a few cases described so far. Here we review 22 reports of the disease found in the literature of the last 25 years. IETSC is closely associated with tuberculous meningitis (TM). Both conditions may occur simultaneously, but more frequently IETSC is preceded by TM. IETSC has been described in a predominantly young population of both genders. The pathogenesis is unknown, although a paradoxical reaction to antituberculous medication is a reasonable possibility. The disease presents insidiously with paraparesis, hypoesthesia with a sensory level, and bladder dysfunction, due to cord involvement or compression by the inflammatory process. Permanent paraparesis is a common sequela. MRI is the diagnostic technique of choice in IETSC. Prompt surgical excision of the tuberculoma is the cornerstone of therapy. Antituberculous treatment is also indicated; unless resistance is present, conventional chemotherapy is probably enough. Corticosteroids are also generally recommended. In conclusion, IETSC is a rare complication of TM, which presents insidiously, despite adequate antituberculous treatment. To avoid the permanent disability that this condition may provoke, an early diagnosis and prompt treatment is critical.

Allergic conjunctivitis: update on pathophysiology and prospects for future treatment.

Allergic conjunctivitis is in actuality a group of diseases affecting the ocular surface and is usually associated with type 1 hypersensitivity reactions. Two acute disorders, seasonal allergic conjunctivitis and perennial allergic conjunctivitis, exist, as do 3 chronic diseases, vernal keratoconjunctivitis, atopic keratoconjunctivitis, and giant papillary conjunctivitis. The ocular surface inflammation (usually mast cell driven) results in itching, tearing, lid and conjunctival edema-redness, and photophobia during the acute phase and can lead to a classic late-phase response (with associated eosinophilia and neutrophilia) in a subset of individuals. As is the case in other allergic diseases, a chronic disease can also develop, accompanied by remodeling of the ocular surface tissues. In severe cases the patient experiences extreme discomfort and sustains damage to the ocular surface. For such cases, there is no highly effective and safe treatment regimen. Topical administration of corticosteroids is used in severe cases but is associated with an increased risk for the development of cataracts and glaucoma. Thus there is a worldwide search for new biotargets for the treatment of these diseases. Here we provide a brief update of the clinical symptoms associated with these diseases, the rationale for disease classification, recent advances in our understanding of the pathogenesis of the diseases, and an update on both preclinical and clinical advances toward refined therapies for these diseases.

The September epidemic of asthma exacerbations in children: a search for etiology.

BACKGROUND: Predictable peaks of asthma exacerbation requiring hospital treatment, of greatest magnitude in children and of uncertain etiology, occur globally after school returns. OBJECTIVE: We wished to determine whether asthmatic children requiring emergency department treatment for exacerbations after school return in September were more likely to have respiratory viruses present and less likely to have prescriptions for control medications than children with equally severe asthma not requiring emergent treatment. METHODS: Rates of viral detection and characteristics of asthma management in 57 (of 60) children age 5 to 15 years presenting to emergency departments with asthma in 2 communities in Canada between September 10 and 30, 2001, (cases) were compared with those in 157 age-matched volunteer children with asthma of comparable severity studied simultaneously (controls). RESULTS: Human picornaviruses were detected in 52% of cases and 29% of controls ( P = .002) and viruses of any type in 62% of cases and 41% of controls ( P = .011). Cases were less likely to have been prescribed controller medication (inhaled corticosteroid, 49% vs 85%; P < .0001; leukotriene receptor antagonist, 9% vs 21%; P = .04). CONCLUSION: Respiratory viruses were detected in the majority of children presenting to emergency departments with asthma during the September epidemic of the disease and in a significant minority of children with asthma in the community. The latter were more likely to have anti-inflammatory medication prescriptions than children requiring emergent treatment. Such medication may reduce the risk of emergency department treatment for asthma during the September epidemic.

Adult asthma severity in individuals with a history of childhood asthma.

BACKGROUND: Childhood asthma can have a range of outcomes in adulthood. OBJECTIVE: To identify clinical features and exposures associated with persistence and severity of childhood asthma in adulthood. METHODS: Eighty-five of 121 subjects previously enrolled in a study of immunotherapy for childhood allergic asthma (age 5-12 years) were re-evaluated with allergy skin testing, spirometry, and interviews about asthma symptoms and medications. These young adults (age 17-30 years; 74% male) all had moderate to severe childhood asthma. Adult asthma severity was scored by using a modified version of National Heart, Lung, and Blood Institute severity categories. RESULTS: Thirteen (15.3%) of 85 adult subjects were in remission despite persistent childhood asthma. Another 19 subjects (22.4%) had only intermittent asthma. The remaining 53 had persistent asthma, of whom 12 (14.1%) had mild asthma, 25 (29.4%) had moderate asthma, and 16 (18.8%) had severe asthma. Subjects in remission, compared with subjects with intermittent or persistent asthma, had lower total serum IgE in childhood (412 ng/mL vs 1136 ng/mL vs 968 ng/mL; P = .02) and fewer positive allergy skin tests (7 vs 9 vs 10 from panel of 18; P = .02). Subjects in remission also had milder childhood asthma, indicated by lower average daily medication usage scores (1.6 vs 3.5 vs 4.4; P = .005) and lower percentage of days on inhaled corticosteroids (13.7% vs 24.7% vs 40.9%; P = .008). No significant association was found between current asthma severity and childhood immunotherapy ( P = .46). CONCLUSION: The prognosis of childhood allergic asthma in adulthood is largely determined early in life. The degree of atopy appears to be a critical determinant of asthma persistence.