Integrating lipid screening with ideal cardiovascular health assessment in pediatric settings

Pediatric lipid screening and management with the aim of reducing and preventing adult disease is an internationally accepted concept, and guidelines have been published in several countries. However, implementation by the practicing pediatric community in the United States has been less than expected and delays have been attributed to uncertainty among providers. Reduced screening rates have also been reported for conditions contributing to arterial wall pathology such as obesity, hypertension, and prediabetes despite accumulating evidence that detection and intervention can lead to risk reversal. Consistent with graded and evidence-based national guidelines for comprehensive cardiovascular risk assessment and management, we present how the American Heart Association ideal cardiovascular health (ICVH) model can be integrated with lipid screening, and how it can be compatible with comprehensive pediatric lipidology practice and enhanced familial hypercholesterolemia detection. Since being introduced and retrospectively validated in adults and children in cross-sectional studies, ICVH evaluates thresholds for seven ideal health metrics representing measurements of obesity, dyslipidemia, diabetes risk, and blood pressure, and includes exercise, diet, and smoking behaviors. When each metric is valued as a point, the maximum health score is 7, but national surveys have shown unacceptable low scores in adolescence. Inverse correlation of scores with arterial structural change supports use of ICVH as a collection of treatable targets forming a cardiovascular prevention construct including and supporting lipid screening in pediatric settings, but implementation in clinical practice requires more expertise and administrative support than lipid screening alone.     

Differing attitudes of industry and academia towards controlled clinical trials

A consensus conference was held in 1984 on controversial issues concerning controlled clinical trials. Thirty-six individuals working in academic institutions, forty-six in industry and twelve in regulatory authorities participated. Academics accepted and industrial representatives rejected the following: existing regulations cannot cope with the rate at which new treatments develop; drug companies may be reluctant to undertake surveillance programmes because sales will fall if adverse reactions are detected; novel remedies should not be promoted before extensive post-marketing surveillance; third parties should finance trials promising to reduce the costs of illness and trialists should be separated from sponsors in data analysis and interpretation, the investigator owning the data unless stated otherwise. Industrial representatives supported and academics rejected the following: government price control inhibits drug development and a multicentre trial can be justified simply by the wish to speed drug registration.     

肝门部胆管癌根治术肝切除范围的合理选择

外科手术切除是肝门部胆管癌最有效和首选的治疗方法,笔者根据该病的4种类型提出合理的手术切除范围选择,旨在进一步规范肝门部胆管癌的外科治疗。     

An evaluation of enteral feeding practices in critically ill children

Background: Establishing and sustaining enteral feeding in critically ill children is challenging and has met with many problems. Aims and objectives: The aim of this study was to investigate (a) how actual calorie intake compared with estimated caloric requirements and (b) whether feeding guideline adherence resulted in improved nutritional intake. Design and methods: A prospective observational study was undertaken over 1 month in a tertiary referral paediatric intensive care unit (PICU) in the northwest of England. Results: Forty‐seven children were studied, with a wide range of diagnoses in a 1‐month period. Only 47% of the children had enteral feeds started within our 6 h post‐admission target. Over half (55%) of the children received less than half of their estimated calorie requirements, but if feeding guidelines were followed, this resulted in a significantly higher (p = 0·004) delivery of the child's estimated requirements. Conclusions: This study found that many children are not receiving adequate nutrition in PICU and that the use of feeding guidelines significantly improves calorie delivery in PICU patients. Relevance to clinical practice: This paper highlights the dearth of research related to enteral feeding in critically ill children. We found that the use of feeding guidelines improved calorie delivery and so units should be encouraged to develop their own guidelines based on the best evidence available.     

Autochthonous Dengue Fever,Tokyo, Japan, 2014

After 70 years with no confirmed autochthonous cases of dengue fever in Japan, 19 cases were reported during August–September 2014. Dengue virus serotype 1 was detected in 18 patients. Phylogenetic analysis of the envelope protein genome sequence from 3 patients revealed 100% identity with the strain from the first patient (2014) in Japan.     

Evidence-based Clinical Practice Guidelines for Interventional Pain Management in Cancer Pain

Intractable cancer pain not amenable to standard oral or parenteral analgesics is a horrifying truth in 10–15% of patients. Interventional pain management techniques are an indispensable arsenal in pain physician''s armamentarium for severe, intractable pain and can be broadly classified into neuroablative and neuromodulation techniques. An array of neurolytic techniques (chemical, thermal, or surgical) can be employed for ablation of individual nerve fibers, plexuses, or intrathecalneurolysis in patients with resistant pain and short life-expectancy. Neuraxial administration of drugs and spinal cord stimulation to modulate or alter the pain perception constitutes the most frequently employed neuromodulation techniques. Lately, there is a rising call for early introduction of interventional techniques in carefully selected patients simultaneously or even before starting strong opioids. After decades of empirical use, it is the need of the hour to head towards professionalism and standardization in order to secure credibility of specialization and those practicing it. Even though the interventional management has found a definite place in cancer pain, there is a dearth of evidence-based practice guidelines for interventional therapies in cancer pain. This may be because of paucity of good quality randomized controlled trials (RCTs) evaluating their safety and efficacy in cancer pain. Laying standardized guidelines based on existing and emerging evidence will act as a foundation step towards strengthening, credentialing, and dissemination of the specialty of interventional cancer pain management. This will also ensure an improved decision-making and quality of life (QoL) of the suffering patients.