Smokeless tobacco: current status and future directions

Smokeless tobacco is addicting, can cause physical dependence, and is associated with many health risks. In spite of these concerns over its use, minimal research has been conducted to understand the effects from and factors associated with smokeless tobacco use. Additionally, relatively few studies have examined potentially effective treatments for the smokeless tobacco user. This paper reviews the existing literature in this area and considers future directions for research.     

Intestinal transplantation: current status and future directions

Three decades after the first intestinal transplant was performed in humans, this life-saving procedure has come of age and now offers hope of long-term survival in a small group of patients with life-threatening complications of intestinal failure and parenteral nutrition. Success rates have greatly improved, largely through advances in immunosuppression protocols, improved surgical technique and postoperative care, and accumulated experience. Management of the intestinal transplant recipient entails careful surveillance, prevention, and treatment of rejection and infection, as well as optimization of feeding and nutrition. With this approach, survival and quality of life are demonstrably improved, such that intestinal transplantation is now an established and accepted procedure for this very select group of highly-complex patients.     

Umbilical cord blood: current status and future directions

Once considered biological waste, umbilical cord blood (UCB) has become an accepted source of haematopoietic stem cells (HSCs). With initial success in the pediatric setting, UCB transplantation continues to gain favor in the adult patient population. Novel approaches to UCB transplantation include use of two units and a variety of graft manipulations. Additional uses for UCB are currently being explored and include applications in regenerative medicine and immunotherapy.     

Renal cell carcinoma: current status and future directions

Although renal cell carcinoma accounts for only 3% of adult malignancies, it has been increasing in incidence by 2-4% per year since the 1970's. Cigarette smoking, obesity and end-stage renal disease are important risk factors. Genetic syndromes such as von Hippel-Lindau disease are also associated with an increased incidence of renal cell carcinoma. Localized disease should be treated with surgical resection. However, approximately 30% of patients present with metastatic disease. Complete resection of metastases can result in long-term survival in some individuals. Removal of the primary renal tumor in patients with unresectable disseminated disease has also been shown to improve survival in selected good performance status patients receiving systemic immunotherapy. While chemotherapy has been relatively ineffective in the treatment of renal cell carcinoma, biologic therapy with interleukin-2 or interferon does lead to responses in a minority of patients, with occasional long-term survivors. Recently, promising results have been reported with allogeneic stem cell transplantation using a non-myeloablative conditioning regimen. However, therapy for metastatic renal cell carcinoma remains inadequate. Ongoing trials with novel approaches such as anti-angiogenesis agents, cyclin-dependent kinase inhibitors, and tumor vaccines will hopefully lead to improved outcomes in this disease.     

脑血管病的康复现状和未来发展方向

康复医学介入脑血管病的后续治疗虽然已近半个世纪,但其效果直到近年来才得到循证医学证实并被学术界认可,有关卒中单元和社区康复的研究尤其引人注目.     

Molecular targets in breast cancer: current status and future directions

Our increasing understanding of the pathophysiologic mechanisms of breast carcinogenesis has generated detailed information about the potential roles of specific biomolecular markers in this process. Furthermore, in the last few years the process of targeted drug design has become faster and more sophisticated, providing a variety of agents targeted at these molecules. In this review, we describe the most widely recognized molecular targets in breast cancer.     

Gambling and substance use disorders: current status and future directions

This paper briefly reviews the clinical presentation of pathological gambling and presents data related to the co-occurrence of pathological gambling and substance use disorders. Both epidemiological and treatment data are reviewed. The putative physiological substrates underlying pathological gambling are described, along with the limited genetics data. Types of treatments applied to gamblers are described, including data on efficacy and overlap of issues that relate to both gambling and substance use disorders. Finally, areas for future research are suggested to advance our understanding of pathological gambling and its relationship to substance use disorders.     

Surgical treatment of arrhythmias: current status and future directions.

A variety of surgical interventions have evolved for the treatment of intractable or life-threatening arrhythmias unresponsive to conventional pharmacologic or pacemaker therapy. Supraventricular arrhythmias associated with rapid ventricular responses can be indirectly treated with ablation of the atrioventricular conduction system and insertion of a pacemaker. Ventricular tachyarrhythmias have previously been treated with sympathectomy, resection of tissue or revascularization. More recent approaches include the simple ventriculotomy, encircling endocardial ventriculotomy, cryosurgical ablation and insertion of the automatic implantable defibrillator. Refinement of methods to localize more precisely the origin of ventricular arrhythmias may allow design of more direct surgical procedures. The surgical treatment of arrhythmias related to the preexcitation syndromes remains the model of electrophysiologic surgery. It is now feasible to divide accessory pathways with a high degree of success and at low risk in selected patients.     

New vision in video capsule endoscopy: current status and future directions

Now, more than 10 years after the approval of video capsule endoscopy (VCE), the technology has become an essential component in the management of several clinical conditions. Currently, two capsules are approved in the USA for visualizing the small bowel mucosa, one capsule is authorized for oesophageal assessment and several others are in use or under evaluation worldwide. New investigations have focused on optical improvements, advances in intestinal cleansing and risk reduction strategies to optimize VCE methodologies in clinical care. Established indications diagnosed using VCE include unexplained gastrointestinal bleeding, small bowel Crohn's disease (in adults and children >10 years old), localization of small bowel tumours and a broad range of miscellaneous abnormalities. Investigations are ongoing to determine the utility of VCE in colon cancer screening, assessment of oesophageal disorders and diagnosis of coeliac disease. Active research is in progress into ways to improve the efficacy of VCE recording interpretation, prolong imaging time and further enhance optics and imaging methods. To expand the potential utility of VCE, novel devices that can manoeuvre within or insufflate the gut lumen, tag or biopsy suspect lesions, or target drug delivery to specific sites are in development. To facilitate these advances, consortia have been organized to promote innovative VCE technologies.     

Outpatient diabetes clinical decision support: current status and future directions

Outpatient clinical decision support systems have had an inconsistent impact on key aspects of diabetes care. A principal barrier to success has been low use rates in many settings. Here, we identify key aspects of clinical decision support system design, content and implementation that are related to sustained high use rates and positive impacts on glucose, blood pressure and lipid management. Current diabetes clinical decision support systems may be improved by prioritizing care recommendations, improving communication of treatment‐relevant information to patients, using such systems for care coordination and case management and integrating patient‐reported information and data from remote devices into clinical decision algorithms and interfaces.     

Magnetic resonance imaging in rheumatoid arthritis: current status and future directions

The performance of alternative imaging endpoints in clinical trials can be compared in terms of validity, rate of change, measurement precision, and convenience and cost. With respect to technical performance, magnetic resonance imaging (MRI) appears to show greater sensitivity than radiography for detecting bone abnormalities in rheumatoid arthritis (RA). In addition to monitoring changes in the bones, cartilage, and synovium, MRI can directly visualize the full spectrum of tendon pathology, and has been shown to identify tendonitis and tendon rupture with greater accuracy than clinical examination. MRI is currently regarded to be the most sensitive imaging technique for identifying trauma, infection, ischemia, and primary and secondary neoplasia of bone. Several studies have also shown MRI to be highly sensitive for detecting what appear to be bone erosions in the hands and wrists of patients with RA. MRI shows remarkable promise as a tool for identifying and monitoring structural damage in the joints of patients with RA. MRI appears to be able to identify bone erosions with greater sensitivity than radiography, and to disclose edema-like changes in the marrow, which may precede actual erosion formation. As new therapies with structure modifying capabilities enter the clinic, the ability to identify patients appropriate for those therapies and then to monitor the effectiveness and safety of treatment become increasingly important.     

Low dose methotrexate in inflammatory bowel disease: current status and future directions

Despite many recent advances, some notable limitations exist in the medical management of patients with inflammatory bowel disease. Glucocorticoids suppress active inflammation very effectively, but their long term use is associated with high rates of relapse and unacceptable toxicity. 6-Mercaptopurine and its prodrug azathioprine are effective in inducing and maintaining remission; however, a significant number of patients are resistant or intolerant to thiopurines. Low dose methotrexate, an anti-inflammatory drug, is a well established medication for rheumatoid arthritis and psoriasis. After an initial report in 1989, several clinical trials and analyses of clinical notes have examined the role of methotrexate in patients with ulcerative colitis and Crohn's disease. This review was conducted to summarize the current knowledge about the underlying basic anti-inflammatory mechanisms of methotrexate as well as the pharmacology and toxicology of this drug with particular emphasis on inflammatory bowel disease. It also critically evaluates all existing trials not only in the induction of remission but also in maintenance therapy. We conclude that low dose methotrexate is an effective and safe treatment in glucocorticoid-dependent and thiopurine intolerant patients with Crohn's disease but not ulcerative colitis. It remains to be seen whether low dose methotrexate may also be useful in long term maintenance therapy in patients with inflammatory bowel disease.