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Abstract
PURPOSE OF REVIEW The treatment of sarcoidosis remains uncertain, despite 70 years of study. The conventional approach is to initiate corticosteroids in individuals who require treatment. The position of more aggressive regimes is unknown. RECENT FINDINGS Recent recognition that many patients will require prolonged therapy, and the observation that corticosteroids lead to overt and insidious toxicities, have led to suggestions that steroid-sparing medications be used earlier in the management of sarcoidosis. Individuals with poor prognostic features, designated as 'high-risk' sarcoidosis may, especially benefit from a broader palette of therapeutic options in the initial treatment regimen. An even more aggressive approach, known as 'top-down' or 'hit-hard and early' therapy has emerged in the fields of gastroenterology and rheumatology in the past 15 years, on the premise that highly effective early control of inflammation leads to better outcomes. These regimens typically involve early initiation of biologic therapies. SUMMARY For certain subpopulations of sarcoidosis patients, 'top-down' therapy could be helpful. Severe pulmonary sarcoidosis, neurosarcoidosis, cardiac sarcoidosis and multiorgan sarcoidosis are phenotypes that may be most relevant for revised therapeutic algorithms. Precision medicine approaches and randomized trials will be necessary to confirm a role for top-down therapy in the routine management of sarcoidosis.
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Affiliation(s)
- Adriane D.M. Vorselaars
- Division Heart and Lungs, University Medical Center Utrecht, Utrecht
- Interstitial Lung Diseases Center of Excellence, Department of Pulmonology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Daniel A. Culver
- Department of Pulmonary Medicine, Respiratory Institute
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Abstract
Introduction: Significant intraindividual and temporal variability in symptom control is a feature of asthma that requires careful monitoring and the need to periodically review and adjust therapy. Both NHLBI/NAEPP and GINA offer helpful algorithms for a stepping approach to asthma.Areas covered: The problems arisen in applying the stepwise approach to the treatment of asthma proposed by NHLBI/NAEPP and GINA algorithms and their possible alternatives.Expert opinion: The current therapeutic stepping approach to asthma, which takes into account lung function, symptoms and quality of life, is certainly useful, but it does not consider the underlying mechanisms. Furthermore, patient's overestimation or underestimation of the severity of the disease and differences in the opinions on the level of asthma control required between patients and physicians and also between physicians in both primary care and specialist settings are common and may negatively affect asthma control and future risks. A reassessment of the conventional stepping approach to management of asthma is now needed. A pragmatic approach that sets therapeutic goals for each individual and associates them with the treatable traits of asthma which, when therapeutically targeted, will in many cases help to achieve the goals, seems more reasonable than the present stepping approach.
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Affiliation(s)
- Mario Cazzola
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Maria Gabriella Matera
- Unit of Pharmacology, Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Paola Rogliani
- Unit of Respiratory Medicine, Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy.,Division of Respiratory Medicine, University Hospital "Tor Vergata", Rome, Italy
| | - Luigino Calzetta
- Respiratory Disease and Lung Function Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Josuel Ora
- Division of Respiratory Medicine, University Hospital "Tor Vergata", Rome, Italy
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Park SH, Lee YS, Cheon SH, Yong MS, Lee D, Lee EJ. Analysis of the ratios of medial-lateral and proximal-distal muscle activities surrounding the hip joint in the step-up and step-down positions. J Back Musculoskelet Rehabil 2019; 32:299-303. [PMID: 30347585 DOI: 10.3233/bmr-160779] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Many practitioners recommend step-up and step-down exercises to increase muscle strength in the lower extremities. However, decreased stability of the hip joint and imbalanced muscle activities can alter limb biomechanics during these movements. OBJECTIVE This study investigated muscle imbalance between the medial and lateral muscle components and between the proximal and distal muscle components by expressing the proportions of muscle activation in the step-up and step-down positions. METHODS Nineteen subjects participated in the study. Activity of the vastus medialis oblique, vastus lateralis, semitendinosus, biceps femoris, adductor, gluteus medius, and gluteus maximus was assessed. RESULTS The semitendinosus-biceps femoris ratio was higher in the step-down position than in the step-up position. The adductor-gluteus medius, adductor-vastus lateralis, and adductor-biceps ratios were higher in the step-up position than in the step-down position. The gluteus maximus-biceps ratio was greater in the step-down position than in the step-up position. In the hip joint, internal rotation was significantly greater in the step-up position. CONCLUSIONS The transverse angle of the hip joint has a greater effect on the medial-lateral balance of the muscles surrounding the hip joint. Muscle activation in the medial hamstring is greater in the step-down position; in the adductor, muscle activation is greater in the step-up position. The step-down position is more appropriate for those with proximal weakness, as it can promote muscle activation in the gluteus maximus while maintaining biceps femoris activation.
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Affiliation(s)
- So Hyun Park
- Department of Physical Therapy, Youngsan University, Yangsan, Korea
| | - Yun-Seob Lee
- Department of Physical Therapy, Youngsan University, Yangsan, Korea
| | - Song Hee Cheon
- Department of Physical Therapy, Youngsan University, Yangsan, Korea
| | - Min-Sik Yong
- Department of Physical Therapy, Youngsan University, Yangsan, Korea
| | - Daehwan Lee
- Rehabilitation Medicine Device Research Institute, G.O. Meditech, Korea
| | - Eun-Ju Lee
- Department of Physical Therapy, Kyungsung University, Busan, Korea
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Lopez-Campos JL, Carrasco Hernández L, Muñoz X, Bustamante V, Barreiro E. Current controversies in the stepping up and stepping down of inhaled therapies for COPD at the patient level. Respirology 2018; 23:818-827. [PMID: 29924458 DOI: 10.1111/resp.13341] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Revised: 05/21/2018] [Accepted: 05/23/2018] [Indexed: 12/23/2022]
Abstract
The implementation of potential new step-up or step-down treatment recommendations in response to current guidelines is one of the main challenges currently faced in actual daily practice settings. In the present narrative review, we aim to discuss the relevance of these step-up and step-down proposals at the patient level in daily clinical practice. In particular, we aim to review the challenges associated with inhaled maintenance therapy for chronic obstructive pulmonary disease (COPD) in four clinical scenarios. First, we discuss the step up from single to double bronchodilation, including current controversies regarding the addition of a second bronchodilator versus initial treatment with two bronchodilators. Second, we discuss the step up from double bronchodilation to triple therapy while challenging current indications for inhaled steroid therapy and discussing triple therapy designs. Third, we discuss the step down from triple therapy to double bronchodilation while evaluating the effect of this downshift in risk categories on the patient according to the new classifications. Finally, we discuss the step down from double to single bronchodilation, with a special focus on safety. We believe this review will help to highlight the most relevant discussion points regarding the treatment of COPD in a manner that will stimulate and guide related clinical research.
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Affiliation(s)
- Jose Luis Lopez-Campos
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBIS), Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Sevilla, Spain
- Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Laura Carrasco Hernández
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBIS), Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Sevilla, Spain
- Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Xavier Muñoz
- Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
- Pulmonology Service, Department of Medicine, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Víctor Bustamante
- Servicio de Neumología, Hospital Universitario Basurto, Osakidetza, Departamento de Medicina, EHU-University of the Basque Country, Vizcaya, Spain
| | - Esther Barreiro
- Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
- Pulmonology Department-Muscle Wasting and Cachexia in Chronic Respiratory Diseases and Lung Cancer Research Group, IMIM-Hospital del Mar, Parc de Salut Mar, Health and Experimental Sciences Department (CEXS), Universitat Pompeu Fabra (UPF), Barcelona Biomedical Research Park (PRBB), Barcelona, Spain
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Kerwin EM, Kalberg CJ, Galkin DV, Zhu CQ, Church A, Riley JH, Fahy WA. Umeclidinium/vilanterol as step-up therapy from tiotropium in patients with moderate COPD: a randomized, parallel-group, 12-week study. Int J Chron Obstruct Pulmon Dis 2017; 12:745-755. [PMID: 28280319 PMCID: PMC5338844 DOI: 10.2147/copd.s119032] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Introduction Patients with COPD who remain symptomatic on long-acting bronchodilator monotherapy may benefit from step-up therapy to a long-acting bronchodilator combination. This study evaluated the efficacy and safety of umeclidinium (UMEC)/vilanterol (VI) in patients with moderate COPD who remained symptomatic on tiotropium (TIO). Methods In this randomized, blinded, double-dummy, parallel-group study (NCT01899742), patients (N=494) who were prescribed TIO for ≥3 months at screening (forced expiratory volume in 1 s [FEV1]: 50%–70% of predicted; modified Medical Research Council [mMRC] score ≥1) and completed a 4-week run-in with TIO were randomized to UMEC/VI 62.5/25 µg or TIO 18 µg for 12 weeks. Efficacy assessments included trough FEV1 at Day 85 (primary end point), 0–3 h serial FEV1, rescue medication use, Transition Dyspnea Index (TDI), St George’s Respiratory Questionnaire (SGRQ), and COPD Assessment Test (CAT). Safety evaluations included adverse events (AEs). Results Compared with TIO, UMEC/VI produced greater improvements in trough FEV1 (least squares [LS] mean difference: 88 mL at Day 85 [95% confidence interval {CI}: 45–131]; P<0.001) and FEV1 after 5 min on Day 1 (50 mL [95% CI: 27–72]; P<0.001). Reductions in rescue medication use over 12 weeks were greater with UMEC/VI versus TIO (LS mean change: −0.1 puffs/d [95% CI: −0.2–0.0]; P≤0.05). More patients achieved clinically meaningful improvements in TDI score (≥1 unit) with UMEC/VI (63%) versus TIO (49%; odds ratio at Day 84=1.78 [95% CI: 1.21–2.64]; P≤0.01). Improvements in SGRQ and CAT scores were similar between treatments. The incidence of AEs was similar with UMEC/VI (30%) and TIO (31%). Conclusion UMEC/VI step-up therapy provides clinical benefit over TIO monotherapy in patients with moderate COPD who are symptomatic on TIO alone.
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Affiliation(s)
| | - Chris J Kalberg
- Respiratory Department, GlaxoSmithKline, Research Triangle Park, NC, USA
| | - Dmitry V Galkin
- Respiratory Department, GlaxoSmithKline, Research Triangle Park, NC, USA
| | - Chang-Qing Zhu
- Clinical Statistics, GlaxoSmithKline, Stockley Park, Uxbridge, Middlesex
| | - Alison Church
- Respiratory Department, GlaxoSmithKline, Research Triangle Park, NC, USA
| | - John H Riley
- Respiratory Department, GlaxoSmithKline, Stockley Park, Uxbridge, Middlesex, UK
| | - William A Fahy
- Respiratory Department, GlaxoSmithKline, Stockley Park, Uxbridge, Middlesex, UK
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Dimitriou D, Tsai TY, Li JS, Nam KW, Park KK, Kwon YM. In vivo kinematic evaluation of total hip arthroplasty during stair climbing. J Orthop Res 2015; 33:1087-93. [PMID: 25626860 DOI: 10.1002/jor.22837] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Accepted: 01/19/2014] [Indexed: 02/04/2023]
Abstract
Stair climbing is a physically demanding task and a painful limitation for patients suffering from severe hip osteoarthritis. Although total hip arthroplasty (THA) is the definitive treatment for end-stage osteoarthritis, it is not well understood whether THA restores hip kinematics during strenuous activities. The purpose of this study was to compare the 3D kinematics of THA and native hip during physically demanding tasks and correlate potential differences with THA components orientations/positions in patients with unilateral THA. In vivo hip kinematics were determined during step-up and leg stance activities using a validated combination of 3D CT-based computer modeling and dual fluoroscopic imaging system (DFIS). The THA side demonstrated an average 3.4° (±6.5°, range: -5.9° to 15.2°) greater internal rotation than the contralateral native hip, during the step-up activity but not during leg stance. The difference in internal rotation was highly correlated to the difference in femoral anteversion and anterior translation of hip joint center between implanted and native hip (R(2) = 0.71, p < 0.01). The results suggest the importance of accurate THA component placement in restoring normal hip kinematics during functional activities.
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Affiliation(s)
- Dimitris Dimitriou
- Department of Orthopaedic Surgery, Bioengineering Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Tsung-Yuan Tsai
- Department of Orthopaedic Surgery, Bioengineering Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jing-Sheng Li
- Department of Orthopaedic Surgery, Bioengineering Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kwang Woo Nam
- Department of Orthopaedic Surgery, Bioengineering Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.,Department of Orthopedic Surgery, Jeju National University, School of Medicine, Jeju, South Korea
| | - Kwan Kyu Park
- Department of Orthopaedic Surgery, Bioengineering Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.,Department of Orthopedic Surgery, Yonsei University, College of Medicine, Seoul, South Korea
| | - Young-Min Kwon
- Department of Orthopaedic Surgery, Bioengineering Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Niess JH, Klaus J, Stephani J, Pflüger C, Degenkolb N, Spaniol U, Mayer B, Lahr G, von Boyen GBT. NOD2 polymorphism predicts response to treatment in Crohn's disease--first steps to a personalized therapy. Dig Dis Sci 2012; 57:879-86. [PMID: 22147245 PMCID: PMC3306782 DOI: 10.1007/s10620-011-1977-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2011] [Accepted: 11/09/2011] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND AIMS Great efforts have been made to predict disease behavior over time and the response to treatment in Crohn's disease (CD). Such understanding could personalize therapy. Early introduction of more aggressive therapies to patients at high risk and no introduction of predictable refractory treatments could become possible. We hence tested the influence of the NOD2 carrier status on treatment response. PATIENTS AND METHODS In 185 CD patients (age 45 ± 9.8 years, female n = 108, minimum disease duration 10 years), the three most common polymorphisms (p.Arg702Trp, p.Gly908Arg, p.Leu1007fsX1008) of NOD2 were tested by polymerase chain reaction and sequencing. Detailed clinical and medical history were obtained with a standardized questionnaire and by reviewing the medical charts. Treatments introduced were chosen by physicians blinded to genotype data. RESULTS The frequency of the NOD2 variant allele was about one-third (67, 30.2%) of CD patients. NOD2 carriers were more often treated with systemic and locally active steroids and with an immunosuppressant (Azathioprine/6-MP). NOD2 mutation carrier status was more often associated with systemic steroid [8.9% vs. wild-type (WT) 1.2%, P = 0.0086] and local-steroid refractory (14.9% vs. WT 3.5%; P = 0.001). The WT patients were significantly higher refractory to immunosuppressant (12.8% vs. NOD2 carriers, 0.5%, P = 0.03). Most WT patients were treated with TNF-α antagonists and remission rates were significantly higher in this group after 1 year of treatment (84% vs. NOD2 carriers, 33%, P = 0.07). CONCLUSIONS The study presents first hints for the NOD2 carrier status to be predictive for response to therapy. A higher percentage of CD patients with NOD2 mutation carrier status was steroid refractory but could be treated well with immunosuppressants. The WT status showed a higher response to steroids and remission rates within 1 year of anti-TNF-α therapy. On the way to personalized medicine, this approach should be further investigated in larger studies.
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Affiliation(s)
- Jan Hendrik Niess
- Department of Medicine I (Gastroenterology), Ulm University, Albert-Einstein-Allee 23, 89081 Ulm, Germany
| | - Jochen Klaus
- Department of Medicine I (Gastroenterology), Ulm University, Albert-Einstein-Allee 23, 89081 Ulm, Germany
| | - Johannes Stephani
- Department of Medicine I (Gastroenterology), Ulm University, Albert-Einstein-Allee 23, 89081 Ulm, Germany
| | - Carolin Pflüger
- Department of Medicine I (Gastroenterology), Ulm University, Albert-Einstein-Allee 23, 89081 Ulm, Germany
| | - Nadine Degenkolb
- Department of Medicine I (Gastroenterology), Ulm University, Albert-Einstein-Allee 23, 89081 Ulm, Germany
| | - Ulrike Spaniol
- Department of Medicine I (Gastroenterology), Ulm University, Albert-Einstein-Allee 23, 89081 Ulm, Germany
| | | | - Georgia Lahr
- Department of Paediatrics, Ulm University, Ulm, Germany
| | - Georg B. T. von Boyen
- Department of Medicine I (Gastroenterology), Ulm University, Albert-Einstein-Allee 23, 89081 Ulm, Germany
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Hopkins JT, Ingersoll CD, Sandrey MA, Bleggi SD. An electromyographic comparison of 4 closed chain exercises. J Athl Train 1999; 34:353-7. [PMID: 16558588 PMCID: PMC1323346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
OBJECTIVE Closed chain exercises are used in the clinical setting to safely strengthen the muscles about the knee. We compared the EMG activity of 3 muscles (vastus lateralis, vastus medialis, and biceps femoris) during 4 closed chain exercises (unilateral one-quarter squat, lateral step-up, FlexCord front pull, and FlexCord back pull) to determine which exercise produced the most muscle activity. DESIGN AND SETTING We used a 4 x 3 x 2 factorial design with repeated measures on exercise, muscle, and movement (knee flexion and extension). Muscle and movement were the control variables for post hoc comparisons. Data were collected in a sports injury research laboratory. SUBJECTS Thirty-eight healthy, active female college students aged 21.97 +/- 2.8 years, with height 166.9 +/- 6.3 cm and weight 61.9 +/- 8.5 kg. Subjects had no history of lower extremity pathology that resulted in surgery and no lower extremity pathology within the last year. MEASUREMENTS We placed surface electrodes on the vastus lateralis, vastus medialis, and biceps femoris muscles. Synchronized with a metronome, subjects performed 3 repetitions of 4 exercises between 5 degrees and 30 degrees of knee flexion. Electromyographic measurements were taken from the middle third of the flexion and extension phase of each repetition. RESULTS The FlexCord front pull and back pull produced higher levels of biceps femoris activity than the quarter squat and step-up. The FlexCord front pull also produced a higher level of vastus medialis activity during knee extension than the quarter squat, lateral step-up, or FlexCord back pull. CONCLUSIONS The high levels of biceps femoris activity during the FlexCord exercises indicate that a greater cocontraction exists. With a greater cocontraction, the FlexCord exercises could be safely used during ACL rehabilitation. The high levels of vastus medialis activity during the FlexCord front pull suggest that it may be a beneficial exercise for patellofemoral rehabilitation.
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