Left Bundle Branch Block,an Old–New Entity

Left bundle branch block (LBBB) is generally associated with a poorer prognosis in comparison to normal intraventricular conduction, but also in comparison to right bundle branch block which is generally considered to be benign in the absence of an underlying cardiac disorder like congenital heart disease. LBBB may be the first manifestation of a more diffuse myocardial disease. The typical surface ECG feature of LBBB is a prolongation of QRS above 0.11 s in combination with a delay of the intrinsic deflection in leads V5 and V6 of more than 60 ms and no septal q waves in leads I, V5, and V6 due to the abnormal septal activation from right to left. LBBB may induce abnormalities in left ventricular performance due to abnormal asynchronous contraction patterns which can be compensated by biventricular pacing (resynchronization therapy). Asynchronous electrical activation of the ventricles causes regional differences in workload which may lead to asymmetric hypertrophy and left ventricular dilatation, especially due to increased wall mass in late-activated regions, which may aggravate preexisting left ventricular pumping performance or even induce it. Of special interest are patients with LBBB and normal left ventricular dimensions and normal ejection fraction at rest but who may present with an abnormal increase in pulmonary artery pressure during exercise, production of lactate during high-rate pacing, signs of ischemia on myocardial scintigrams (but no coronary artery narrowing), and abnormal ultrastructural findings on myocardial biopsy. For this entity, the term latent cardiomyopathy had been suggested previously.     

New Developments in the Diagnosis and Treatment of Pancreatic Cancer

The prognosis of pancreatic cancer is poor. Less than 5% of patients diagnosed with pancreatic cancer survive more than 5 years. Generally, the advanced stage, the late diagnosis and the poor therapeutic options are assumed to be responsible for this poor prognosis. Nonetheless, in recent years our knowledge of the pathogenesis of pancreatic cancer has dramatically improved and will give rise to new therapeutic options based on molecular alterations, which contribute to pancreatic carcinogenesis. Furthermore, new diagnostic procedures offer a new perspective towards a better and earlier diagnostic management of these individuals affected with this malignancy.     

Value of Digoxin in Heart Failure and Sinus Rhythm: New Features of an Old Drug?

Digoxin has been a controversial drug since its introduction >200 years ago. Although its efficacy in patients with heart failure and atrial fibrillation is clear, its value in patients with heart failure and sinus rhythm has often been questioned. In the 1980s, reports of some large-scale trials indicated that digoxin, with or without vasodilators or angiotensin-converting enzyme inhibitors, reduced signs and symptoms of congestive heart failure and improved exercise tolerance. This beneficial influence was mainly found in patients with more advanced heart failure and dilated ventricles, whereas the effect in those with mild disease appeared to be less pronounced. In the last few years, new data have shown that digoxin may also have clinical value in mild heart failure, either when used in combination with other drugs or when administered alone. As neurohumoral activation has increasingly been recognized to be a contributing factor in the disease progression of chronic heart failure, the modulating effects of digoxin on neurohumoral and autonomic status have received more attention. Also, there is evidence that relatively low doses of digoxin may be at least as effective as higher doses and have a lower incidence of side effects. Further, the recognition that the use of digoxin too early after myocardial infarction may be harmful and the development of other drugs, in particular angiotensin-converting enzyme inhibitors, have obviously changed the place of digoxin in the treatment of chronic heart failure. The large-scale survival trial by the Digitalis Investigators Group (DIG), whose preliminary results have recently been presented, has shown that although digoxin has a neutral effect on total mortality during long-term treatment, it reduces the number of hospital admissions and deaths due to worsening heart failure. The potentially new features of the old drug digoxin are discussed in this review.     

New technologies in the gastrointestinal clinic and research： Impedance and high-resolution manometry

The last five years have been an exciting time in the study of esophageal motor disorders due to the recent advances in esophageal function testing. New technologies have emerged, such as intraluminal impedance, while conventional techniques, such as manometry, have enjoyed many improvements due to advances in transducer technology, computerization and graphic data presentation. While these techniques provide more detailed information regarding esophageal function, our understanding of whether they can improve our ability to diagnose and treat patients more effectively is evolving. These techniques are also excellent research tools and they have added substantially to our understanding of esophageal motor function in dysphagia. This review describes the potential benefits that these new technologies may have over conventional techniques for the evaluation of dysphagia.     

Early Experience With New Transcatheter Mitral Valve Replacement

Background

Transcatheter mitral valve replacement (TMVR) is a potential therapy for patients with symptomatic, severe mitral regurgitation (MR). The feasibility of this therapy remains to be defined.

Trials and Tribulations of Assessing New Imaging Protocols: Combining Vasodilator Stress With Exercise

Among all patients referred for stress myocardial perfusion imaging (MPI), a substantial proportion in contemporary practice cannot exercise. Another group of patients are those who are thought to be able to achieve an adequate workload with treadmill (or bicycle) exercise but do not achieve at least 85% of maximum predicted heart rate without developing symptoms. There has been substantial interest and literature on the adjunctive use of vasodilator stress during the same visit to generate best-quality results for patients who do not exercise adequately. Current American Society of Nuclear Cardiology Guidelines recommend the possible use of vasodilator stress agents to supplement exercise in those patients who do not achieve target heart rate. However, optimal timing of administration is not clear. Herein, we summarize literature to date on the combination of vasodilator and exercise stress testing in light of the recently published Exercise to Regadenoson in Recovery Trial (EXERRT).     

Is Being a Grandmother Being Old? Cross-Ethnic Perspectives from New Zealand

This paper draws on a study of social aging among women in urban New Zealand for a comparative analysis of grandmother as a marker of being socially old. The paper features the views and perspectives of the women themselves and examines ethnic group identification as a source of variation. Data collected in a series of indepth interviews with women representing four ethnic groups indicate similar patterns regarding prevalence of transition to the role and recognition of grandmother as one of the roles treated by others as primary in definition of old, but differences regarding how the role is treated in self definitions. In the women's own definitions, being a grandmother is treated as one among a configuration of markers of old age and its significance rests on how the role connects with the other markers. Six other markers were implicated: a shorter future, social generativity, social status, seniority, social renewal, and social integration. Ethnic variation in how the grandmother role connects is evident in respect to all six and relatively strong in the case of social status, seniority, social renewal, and social integration. Indicated for further study is the influence of ethnic culture and also the interaction of ethnicity with other sources of variation such as age in years and marital status.     

Is There any Difference Between the Glomerular Filtration Rate of Patients With Chronic Hepatitis B and C and Patients With Cirrhosis?

Background

Renal dysfunction is a major determinant of the Model of End-stage Liver Disease (MELD) score. The implementation of the MELD score has shifted allocation of livers to patients with renal dysfunction.

Objectives

The aim of our study was the assessment of estimated Glomerular Filtration Rate (eGFR) by the Modification of Diet in Renal Disease 4 (MDRD4) method in patients with HBV chronic hepatitis, HCV chronic hepatitis, and cirrhosis (CH) caused by these viruses to detect any differences in renal function among these diseases.

Patients and Methods

We performed a cross-sectional analysis of all consecutive patients with HBV chronic hepatitis, HCV chronic hepatitis, and cirrhosis caused by these viruses hospitalized during a 4 year period in the Gastroenterology and Hepatology department of the Emergency County Hospital Timisoara, Romania. The eGFR was assessed by the MDRD4 method. Statistical analysis (unpaired t-test, ANOVA, Chi Square test) was performed using OpenEpi 2.3.1.

Results

HBV chronic hepatitis, HCV chronic hepatitis, and cirrhosis secondary to these viruses were associated with a reduction of the GFR. The eGFR was higher in patients with HBV chronic hepatitis than in patients with HCV chronic hepatitis (P < 0.001). Patients with cirrhosis secondary to HBV infection had a higher eGFR than patients with cirrhosis secondary to HCV (P = 0.01). The eGFR of patients with HCV chronic hepatitis was higher than the eGFR of patients with cirrhosis due to this virus (P < 0.001).

Conclusions

Functional renal impairment in diseases caused by HCV was more important than in diseases caused by HBV. The eGFR was statistically lower in cirrhosis secondary to HCV than in HCV chronic hepatitis.     

Introduction: Aging in Asia—Perennial Concerns on Support and Caring for the Old

This introductory article provides background to an understanding of "Aging in Asia," focusing on the demographics of population aging in Asia. It discusses the differences in the magnitude of the aged population in different parts of Asia and highlights the perennial concerns of care and support facing the aged and their families as Asian societies grapple with the graying population. Globalization is one important factor presenting new challenges as well as opportunities to aging Asia. The introduction substantiates the discussions in this special issue, which range from an examination of broad issues of support for the aged and policy directions in East and Southeast Asia, to specific concerns relating to activity and elderly in Singapore, intergenerational relationships in Korea, and issues concerning caregiving of the old in Singapore.