Asthma in the elderly

Asthma is common in the elderly population and the differences between younger and older asthmatics should be appreciated (Table 2). Asthma is frequently overlooked in the geriatric population. Objective measures of pulmonary function can aid in a prompt diagnosis and lead to effective treatment and improved quality of life. Because smoking is an important risk factor for asthma-like symptoms of wheezing, cough, and sputum production, asthma is frequently confused with COPD. When airflow obstruction is found, attempts to demonstrate reversibility can uncover an asthmatic component to the disease. In patients who have asthma symptoms and no airflow obstruction, methacholine testing is helpful. When a normal methacholine challenge is present, a diagnosis of asthma can be excluded and the physician can pursue other diagnostic considerations such as heart failure, chronic aspiration syndrome, pulmonary embolic disease, and carcinoma of the lung. The onset of wheezing, shortness of breath, and cough in an elderly patient is likely to cause concern. Although the adage "all that wheezes is not asthma" is true at any age, it is especially true in the elderly. Diagnosis based on objective measures is essential.     

Primary pulmonary lymphoma.

Three distinct entities are now covered by the definition of primary pulmonary clonal lymphoid proliferation. The aim of this review is to describe the pathophysiological, diagnostic, prognostic and therapeutic aspects of these three entities. Low-grade pulmonary B-cell lymphoma is the most frequent form of primary pulmonary clonal lymphoid proliferation. It arises from mucosa-associated lymphoid tissue. It is usually indolent and appears in the form of a chronic alveolar opacity. The prognosis is excellent, but treatment is controversial (simple monitoring, surgery or single-agent chemotherapy). High-grade pulmonary B-cell lymphoma is far rarer and usually occurs in individuals with an underlying disorder (e.g. immunodeficiency). The prognosis is poor and therapeutic options depend on the underlying disorder. The inclusion of lymphomatoid granulomatosis in the definition of primary pulmonary lymphomas is controversial. The clonal nature of the proliferation is very rarely demonstrated and extrapulmonary involvement is frequent (upper airways, skin, kidneys, central nervous system, etc.). The prognosis is extremely variable, with some authors reporting complete remission with steroids and cyclophosphamide and others reporting failure of combination chemotherapy.     

MRI diagnosis of cavernous sinus invasion by pituitary adenomas

Several MRI signs are helpful for the preoperative MRI diagnosis of cavernous sinus invasion by an adenoma. The first step is to analyse the percentage of encasement of the intracavernous ICA by the adenoma. If this percentage is greater than or equal to 66%, the cavernous sinus is invaded. If the percentage of encasement of intracavernous CA is less than 25%, the cavernous sinus is not invaded. If the percentage of encasement is between 25 and 66%, the analysis of the cavernous venous compartment, the drawing of intercarotid lines and the analysis of the shape and venous compartments of the cavernous sinus are necessary. The cavernous sinus invasion remains very likely if the carotid sulcus venous compartment is obliterated, or if the lateral intercarotid line is crossed. Conversely, if the median intercarotid line is uncrossed, the superior venous compartment is visible, the cavernous sinus is of normal size, or there is no bulging of its lateral dural wall, invasion of the cavernous sinus space can reliably be excluded.     

Antipsychotic drugs and diabetes—an application of the Austin Bradford Hill criteria

There is concern that antipsychotic drugs cause diabetes. Although there has been an explosion in the quantity of literature about this subject, it remains confusing and inconsistent. To assess whether the association between antipsychotic drugs and diabetes is causative, we applied the Austin Bradford Hill criteria to the available evidence. In support of a causative relationship, there is temporality for some cases of diabetes, and there is a biologically plausible explanation. The causative link between antipsychotic drugs and diabetes is coherent with our understanding of diabetes and there are other analogies. However the strength of association is weak, there is lack of consistency or specificity, and there is little evidence to support a biological gradient. We should therefore conclude that the evidence surrounding a causative link between antipsychotic drugs and diabetes is inconclusive. Moreover, the risk is probably low and the attributable risk of developing diabetes is greater for traditional risk factors such as family history, ethnicity, obesity and ageing than it is for receiving an antipsychotic drug. Consequently, the majority of patients receiving second-generation antipsychotics will not develop diabetes as a result of their medication.Electronic Supplementary Material Supplementary material is available for this article at     

Hartmann's procedure or primary anastomosis?

Perforation following acute diverticulitis is a typical scenario during the first attack. Different classification systems exist to classify acute perforated diverticulitis. While the Hinchey classification, which is based on intraoperative findings, is internationally best known, the German Hansen-Stock classification which is based on CT scan is widely accepted within Germany. When surgery is necessary, sigmoid colectomy is the standard of care. An important question is whether patients should receive primary anastomosis or a Hartmann procedure subsequently. A priori there are several arguments for both procedures. Hartmann's operation is extremely safe and, therefore, represents the best option in severely ill patients and/or extensive peritonitis. However, this operation carries a high risk of stoma nonreversal, or, when reversal is attempted, a high risk in terms of morbidity and mortality. In contrast, primary anastomosis with or without loop ileostoma is a slightly more lengthy procedure as normally the splenic flexure needs to be mobilized and construction of the anastomosis may consume more time than the Hartmann operation. The big advantage of primary anastomosis, however, is that there is no need for the potentially risky stoma reversal operation. The most interesting question is when to do the Hartmann operation or primary anastomosis. Several comparative case series were published showing that primary anastomosis is feasible in many patients. However, no randomized trial is available to date. It is of note, that all non-randomized case series are biased, i.e. that patients in better condition received anastomosis and those with severe peritonitis underwent Hartmann's operation. This bias is undoubtedly likely to be present, even if not obvious, in the published papers! Our own data suggest that this decision should not be based on the extent of peritonitis but rather on patient condition and comorbidity. In conclusion, sigmoid colectomy and primary anastomosis is feasible and safe in many patients who need surgery for perforated diverticulitis, particularly when combined with loop ileostomy. Based on our own published analysis, however, we recommend performing Hartmann's operation in severely ill patients who carry substantial comorbidity, while the extent of peritonitis appears not to be of predominant importance.     

The altruistic medical researcher: gone and forgotten?

With increasing economic, political, and bureaucratic involvement in research, there is little focus on the medical researcher's idealistic and benevolent intentions. Benevolence is a pillar of ethical human-subjects research, and altruism is a form of benevolence that is difficult to quantify. It is interest in the welfare of others without personal benefit. This article examines the extent of altruism in medical research from philosophical, psychological, and practical points of view. With the emergence of experimental human trials in the first half of the century, the fame and recognition of physicians largely precluded altruistic motivation. From the philosophical perspective, altruism is at best an optional moral principle. It is not evident in ethical guidelines. In the scientific process, altruism can exist only in ethical and properly designed research. Egoism, scientific misconduct, and conflicts of interest undermine it; but altruism is also a potential solution for these problems. Research is not globally oriented and has an unjust distribution. In an evolutionary model, altruism cannot thrive due to its lack of rewards and feedback, particularly in the economic climate of today's science. Anonymity is decreasing, selfishness is increasing. Research has become an industry, and virtuous ideals are a romantic notion. If we use altruism as an indicator, then its rarity and fragility indicate research's unhealthy state.     

Benign ulceration of the gecum presenting with massive hemorrhage

Massive gastrointestinal hemorrhage secondary to benign cecal ulceration is a rare occurrence. The diagnosis of bleeding from this benign condition is rerely entertained and is often a finding on a pathologic examination. A case of massive hemorrhage from a cecal ulcer is presented, and the literature is reviewed. The role of angiographic demonstration of the lesion, if angiography is readily available, is emphasized, but surgery is the definitive therapy.     

Treatment of Helicobacter pylori infection

Helicobacter pylori is a serious, chronic, progressive, and transmissible infection associated with a significant morbidity and mortality, which alone emphasizes the priority of developing adequate prophylactic or therapeutic measures. What was previously termed "asymptomatic H. pylori infection" is now recognized as a latent infection, and it is now accepted that the presence of an H. pylori infection is an indication for eradication therapy. Successful cure of H. pylori infection requires 2 or more antibiotics. Antibiotic resistance is the major impediment of cure. The ideal duration of therapy is unknown, but in general, 1 week therapy is less effective than longer durations. Compliance is important for the success of treatment; therefore, the favored regimen should have the least side effects. At present, a proton pump inhibitor (or ranitidine bismuth citrate)-clarithromycin triple therapy with either amoxicillin or metronidazole, for at least 10 days is considered first-line therapy. The alternative is quadruple therapy containing a proton pump inhibitor, bismuth, tetracycline, and a higher dose of metronidazole. Quadruple therapy is the best choice after failure of proton pump inhibitor-clarithromycin triple therapy. Confirmation of successful therapy with a urea breath test or a stool antigen test is now the standard of practice.     

Improvement of the method of collection of blood flowing from the adrenal glands in the experiment on dogs

Blood from the adrenal gland can flow in two directions--into the caudal vena cava and by anastomoses into the portal vein. A method of multiple blood procuring from these vessels in dogs for the purpose of studying the adrenal gland function is suggested. Polyethylene catheters, 0.9 mm in diameter and 35--40 mm in length glued to capron plates, mandrins, Gordeev's needles and blood-drawing needles are necessary. Transperitoneal surgical approach to the caudal and mesenteric veins is to be provided. Purse-string suture is applied on the wall of the mesenteric vein. The catheter is washed with heparin, the mandrin is introduced into it and it is inserted into the Gordeev's needle. A puncture is made in the centre of the purse-string suture with this needle, which is introduced into the vein together with the catheter. Gordeev's needle is withdrawn and the catheter is pushed through to the portal vein. The purse-string suture is tightened, and the capron plate is fixed in the wall of the vein. The mandrin is recovered from the catheter, heparin is administered into its canal, polyethylene plug is inserted and withdrawn through the abdominal wall outside with the aid of the blood-drawing needle. The catheter is introduced into the caudal vena cava in the same way. Blood samples can be obtained on the 14th postoperative day.     

Cirrhotic patients and older people

The global population is aging, and so the number of older cirrhotic patients is increasing. Older patients are characterised by a risk of frailty and comorbidities,and age is a risk factor for mortality in cirrhotic patients. The incidence of nonalcoholic fatty liver disease as an aetiology of cirrhosis is increasing, while that of chronic viral hepatitis is decreasing. Also, cirrhosis is frequently idiopathic. The management of portal hypertension in older cirrhotic patients is similar to that in younger patients, despite the greater risk of treatment-related adverse events of the former. The prevalence of hepatocellular carcinoma increases with age, but its treatment is unaffected. Liver transplantation is generally recommended for patients 70 years of age. Despite the increasing prevalence of cirrhosis in older people, little data are available and few recommendations have been proposed.This review suggests that comorbidities have a considerable impact on older cirrhotic patients.     

Ayurveda and Yoga in Cardiovascular Diseases

Ayurveda is derived from 2 Sanskrit words, namely, "Ayus" and "Veda," meaning life and knowledge, respectively. It literally means science of life. Ayurveda, of which yoga is an integral part, is widely practiced in India and is gaining acceptance in many countries around the world. It is a comprehensive and a holistic system, the focus of which is on the body, mind, and consciousness. The Ayurvedic treatment consists of the use herbal preparations, diet, yoga, meditation, and other practices. Based on the review of available studies, the evidence is not convincing that any Ayurvedic herbal treatment is effective in the treatment of heart disease or hypertension. However, the use of certain spices and herbs such as garlic and turmeric in an overall healthy diet is appropriate. Many herbs used by Ayurvedic practitioners show promise and could be appropriate for larger randomized trials. Yoga, an integral part of Ayurveda, has been shown to be useful to patients with heart disease and hypertension. Yoga reduces anxiety, promotes well-being, and improves quality of life. Its safety profile is excellent. Its use as a complementary therapeutic regimen under medical supervision is appropriate and could be worth considering.     

北京航空航天大学的消化性溃疡病发病情况调查报告

本文对北京航空航天大学10739人教职员工作了消化性溃疡病的发病情况的有关调查,发现消化性溃疡病的总发病率为1.3％,男女之比为3.24∶1(十二指肠溃疡2.84∶1;胃溃疡4.32∶1)。其中以教师发病率最高(62.86％),O型血的发病率为40.29％,并发症的发生率为55.71％。     

Tracheobronchopathia osteochondroplastica

Tracheobronchopathia osteochondroplastica (TPO) is an uncommon benign disease of unknown etiology characterized by multiple cartilaginous or bony submucosal nodules, which project into the tracheobronchial lumen. The nodules originate in the airway cartilages and thus typically spare the posterior membranous wall of the airways. The disorder is more common in men and the diagnosis is usually made in the fourth through sixth decades of life. There is no relationship to smoking or other systemic disorders. The disease is manifested by chronic cough and wheezing, which frequently lead to the mistaken diagnosis of asthma. Other pulmonary symptoms include dyspnea and hemoptysis. One of the complications is the increased incidence of recurrent respiratory infections. The pulmonary symptoms and complications are the consequence of narrowing and thickening of the airway walls. Even though roentgenologic imaging studies may indicate the diagnosis, bronchoscopy is the most definitive diagnostic test. The bronchoscopic appearance alone is diagnostic of the disease, and biopsy of the airway lesions is seldom, if ever, required. Although there is no specific therapy for this disorder, management of tracheobronchopathia osteochondroplastica includes bronchodilators, prompt treatment of pulmonary infections, and bronchoscopic dilatation when indicated.     

Germination and growth of neurospora at low water activities

When the water activity (a_w) of the medium is lowered by the addition of NaCl or nonelectrolytes, an inhibition of germination, growth rate, and total growth is observed in Neurospora crassa. Inhibition of conidial germination is separable from the other effects and is caused, in large measure, by the loss from conidia in media of low water activity of a substance that is essential for their germination. The substance is detectable in the medium and is also extractable from cultures. It is dialysable and thermostable, and it appears to be highly active. It is not detectable in complete medium.     

The difference between a dynamic and mechanical approach to stroke treatment

The current classification of stroke is based on causation, also called pathogenesis, and relies on binary logic faithful to the Aristotelian tradition. Accordingly, a pathology is or is not the cause of the stroke, is considered independent of others, and is the target for treatment. It is the subject for large double-blind randomized clinical therapeutic trials. The scientific view behind clinical trials is the fundamental concept that information is statistical, and causation is determined by probabilities. Therefore, the cause and effect relation will be determined by probability-theory-based statistics. This is the basis of evidence-based medicine, which calls for the results of such trials to be the basis for physician decisions regarding diagnosis and treatment. However, there are problems with the methodology behind evidence-based medicine. Calculations using probability-theory-based statistics regarding cause and effect are performed within an automatic system where there are known inputs and outputs. This method of research provides a framework of certainty with no surprise elements or outcomes. However, it is not a system or method that will come up with previously unknown variables, concepts, or universal principles; it is not a method that will give a new outcome; and it is not a method that allows for creativity, expertise, or new insight for problem solving.     

Substitution of thyroid hormones

In patients with overt hypothyroidism the substitution with Levothyroxine is mandatory, whereas in patients with subclinical hypothyroidism it is dependent on further clinical signs and symptoms. The main parameter indicating sufficient substitution of Levothyroxine in patients with primary hypothyroidism is TSH, whereas in secondary hypothyroidism it is free T(4). At present Levothyroxine is the preparation of choice to restore euthyroidism in hypothyroid patients because it is assumed that the peripheral conversion from T(4) to T(3) provides the exact amount of T(3) needed by every organ. Intestinal absorption of Levothyroxin is around 80%, but only in acid environment and is significantly decreased by proton-pump inhibitors, antacids, atrophic gastritis and Helicobacter pylori infection. The usual required dosage of Levothyroxine is 1.5 microg/kg of body weight but is increased under these conditions as well as during early childhood and pregnancy, and is decreased in older people. The bioavailability of different Levothyroxin generics might change between 0.8 and 1.25. Therefore, the thyroid function of patients, receiving another brand of Levothyroxine has to be re-checked.     

Diagnosis and management of IBS

IBS is a common gastrointestinal condition characterized by chronic or recurrent abdominal pain associated with altered bowel habits. IBS is considered a functional bowel disorder (that is, not defined by structural or biochemical abnormalities) and is diagnosed using symptom-based criteria. Limited and judicious use of diagnostic testing is recommended, particularly in patients with typical symptoms of IBS without alarm signs and symptoms. Management of IBS is based on a multifactorial approach and includes establishment of an effective patient-provider relationship, education, reassurance, dietary alterations, pharmacotherapy, behavioral and psychological treatment. Patient-centered care is recommended, in which management is focused on the patient's most bothersome and impactful symptoms, their preferences and previous experiences with treatment, and addressing factors associated with the onset and exacerbation of symptoms. Pharmacotherapy is typically targeted against the predominant symptom. This Review discusses the current evidence-based recommendations for the diagnosis and management of IBS. An improved understanding of the recommended diagnostic and therapeutic approaches for IBS will lead to greater patient satisfaction, as well as reduced health-care costs.     

Autoimmune pancreatitis and IgG-positive sclerosing cholangitis

Sclerosing cholangitis is a heterogenous disease. Sclerosing cholangitis with an unknown cause is abbreviated PSC. PSC affects extra- as well as intra-hepatic bile ducts and since this is a permanently progressing fibrous condition, it leads to liver cirrhosis. The disease is often associated with a development of cholangocarcinoma and idiopathic intestinal inflammation. Causal therapy does not exist; liver transplantation is indicated. IgG4 cholangitis differs from PSC in a number of features. This form is, unlike PSC, linked to autoimmune pancreatitis (AIP) as well as other IgG4 sclerosing diseases. Anatomically, distal region of ductus choledochus is most frequently involved. Icterus is, unlike in PSC, a frequent symptom of AIP. There also is a distinctive histological picture--significant lymphoplasmatic infiltration of the bile duct wall with abundance of IgG4 has been described, lymphoplasmatic infiltration with fibrosis in the periportal area and the presence of obliterating phlebitis is also typical. However, intact biliary epithelium is a typical feature. IgG4 can be diagnosed even without concurrent presence of AIP. IgG4 sclerosing cholangitis is a condition sensitive to steroid therapy. At present, there is no doubt that IgG4 sclerosing cholangitis is a completely different condition to primary sclerosing cholangitis. From the clinical perspective, these diseases should be differentiated in every clinician's mind as (a) AIP is treated with corticosteroids and not with an unnecessary surgery, (b) IgG4 sclerosing cholangitis is mostly successfully treated with corticosteroids and the disease is not, unlike PSC, a risk factor for the development of cholangiocarcinoma.     

II. Malignant potential of gastric polyps.

The malignant potential of gastric polyps is correlated to their features. The vast majority can be divided into two types: hyperplastic polyp and ademona. Hyperplastic polyp is composed of well-differentiated glands and rarely becomes malignant. It is small, smooth-surfaced, often multiple, and randomly distributed. Adenoma is composed of dysplastic glands and often becomes malignant. The small adenoma is flat-surfaced and slightly raised. The large adenoma is papillary and broad-based. Adenoma is usually single and located in the antrum. In either case, a separate independent carcinoma may be present in the same stomach.