Flexible Percutaneous Pericardioscopy: Inherent Drawbacks and Recent Advances

Pericardioscopy enables endoscopic inspection and aimed biopsy of the parietal and visceral pericardium. To elucidate possible technical modifications contributing to the feasibility, diagnostic value and safety of the procedure, pericardioscopy with and Olympus HYF-1T flexible endoscope was performed in 32 patients (53.1% males, mean age 46.2 - 13.1 years) with pericardial effusions. In all patients, the intial step of the procedure was subxiphoid fluoroscopically controlled pericardiocentesis and drainage of the pericardial effusion. An Olympus FB-41ST biopsy forceps was applied for endoscopically guided pericardial biopsies. Standard sampling was used in 22/32 patients (3 to 6 samples/patient) and extensive sampling in 10/32 patients (18 to 20 samples/patient). In additional 12 patients pericardial biopsy was performed without pericardioscopy, under fluoroscopic control. Endoscopic visualization was clearly superior when pericardial effusion was partially replaced with 100 to 300 ml of air (29/32 procedures) in comparison to 3/32 procedures in which the pericardial effusion was replaced with warm normal saline (37 °C). In patients with hemorrhagic effusion (12/32), we either repeatedly injected and removed 100 to 150 ml volumes of normal saline (37 °C), or postponed pericardioscopy for 2 to 3 days of active drainage. The specificity of endoscopic findings is low and not decisive for the diagnosis. However, pericardioscopy is significantly contributing to the diagnostic value of pericardial biopsy, especially regarding establishing the new diagnosis and etiology of the pericardial disease. Sampling efficiency was also significantly higher for procedures using aimed pericardial biopsy with standard and extensive sampling compared to procedures performed under fluoroscopy: 86.2%, 87.3% and 43.7%, respectively. No major complications directly related to the procedure were encountered. Minor complications included: short-run ventricular tachycardia (6.3%), pain at the sheath entry site (75%) and transient fever (37.5%). In conclusion, pericardioscopy with Olympus HYF-1T, after air instillation, is a technically complex, but safe procedure that enables excellent visualization and extensive pericardial sampling with improved diagnostic value of pericardial biopsies. Zusammenfassung Ziel dieser Untersuchung war es zu prüfen, welchen Stellenwert die perkutane Perikardioskopie für Diagnostik und Therapie von Patienten mit ätiologisch unklaren Perikardergüssen einnimmt und welche Verbesserungsmöglichkeiten es für die Bildgebung gibt. Bei 32 Patienten mit Perikarderguss (53,1% Männer, mittleres Alter 46,2 - 13,1 Jahre) erfolgte die Perikardioskopie mit dem flexiblen Olympus-HYF-1T-Endoskop. Für die endoskopisch gesteuerte Perikardbiopsie wurde bei allen Patienten eine FB-41ST-Olympus-Biopsiezange verwendet. Bei 22/32 Patienten wurden drei bis sechs Proben/Patient entnommen (Gruppe 1, Standard Sampling) und bei 10/32 Patienten 18 bis 20 Proben/Patient (Gruppe 2, Extensive Sampling). Außerdem wurde die Bildqualität bei Instillation von 0,9%iger Kochsalzlösung mit der nach Instillation von Luft verglichen. Bei Patienten mit hämorrhagischem Perikarderguss (12/32) erfolgte eine Perikardspülung mit Kochsalzlösung. Die Perikardioskopie wurde zwei bis drei Tage nach Spülung und Drainage vorgenommen. Die optische Qualität der Perikardioskopie war deutlich besser nach Ersatz des Perikardergusses mit 100 bis 300 ml Luft (29/32 Prozeduren) im Vergleich zu den Patienten, bei denen der Erguss mit 0,9%iger Kochsalzlösung (37 °C) ersetzt worden war. Die Spezifität des endoskopischen Befundes allein ist gering. Dagegen trägt die Perikardioskopie insofern erheblich zur diagnostischen Wertigkeit der Epi-/Perikardbiopsie bei, als sie eine gezielte Biopsie makroskopisch auffälliger Stellen erlaubt. Die Ausbeute an Biopsien war mittels perikardioskopischer Steuerung des Bioptoms deutlich besser als unter reiner Röntgenkontrolle (86,2% in Gruppe 1, 87,3% in Gruppe 2 bei Biopsieentnahmen unter Perikardioskopie und 43,7% in Gruppe 3 unter alleiniger Röntgenkontrolle). Ventrikuläre Rhythmusstörungen (6,3%), intermittierendes Druckgefühl (75%) und kurzzeitige Temperaturerhöhungen (37,5%) waren die einzigen Komplikationen. Die Perikardioskopie mit dem Olympus HYF-1T, verbessert durch Luftinstillation, ist eine sichere Methode zur Visualisierung von Perikard und Epikard und zur Vorbereitung einer oder mehrerer Biopsien. Diese sind zusammen mit der Zytologie die Voraussetzung für eine exakte ätiologische Diagnose eines Perikardergusses.     

Cellulitis: definition, etiology, and clinical features

Cellulitis is a common condition seen by physicians. Over the past decade, skin and soft tissue infections from community-associated methicillin-resistant Staphylococcus aureus have become increasingly common. In this article, the definition, etiology, and clinical features of cellulitis are reviewed, and the importance of differentiating cellulitis from necrotizing soft tissue infections is emphasized. Empiric antimicrobial recommendations are suggested, including the most recent recommendations from the Infectious Disease Society of America.     

肝衰竭:定义、诊断与治疗

肝衰竭是临床上常见的严重肝病证候群,在我国尤其多见于重型肝炎,病死率极高.尽管国内外学者在对肝衰竭发病机制和诊治长期不懈的探索中取得了较大进步,但在肝衰竭的定义、分类及诊断方面尚未取得一致意见,尤其是此类患者的救治尚无突破性进展[1].     

The value and limitation of radionuclide angiocardiography with stress in women

The radionuclide angiograms (RNA) with exercise of 64 females were reviewed. There were 30 patients with coronary artery disease, 5 normal controls, 6 patients with normal coronary arteries and hemodynamics, and 23 patients with cardiomyopathy (left ventricular end-diastolic pressure ?15 or ?18 pre- and postangiogram). In the coronary artery disease group, 12 of the 30 (40%) had ST-segment depression and another 12 (40%) had a wall motion abnormality with exercise. In the cardiomyopathy group, 8 of the 23 (35%) had ST-segment depression, and (26%) developed wall motion abnormality with exercise. In the normal coronary group, 2 of the 6 (33%) had a positive ST-segment response, and none had a wall motion abnormality with exercise. The ejection fraction (EF) response with exercise in the normal coronary group was 65.4-72% (p<0.02), in the coronary artery disease group 59.1-56.2% (p<0.025), and in the cardiomyopathy group 62-58.8% (p<0.03). If °EF?5 units with exercise was the normal response, then 5 of 11 (45%) normals were misclassified. If °EF>0 was a normal response, then the specificity was 10 of 11 (91%) for normals or 5 of 6 (83%) for the normal coronary group at angiography. The sensitivity for coronary artery disease was 23 of 30 (77%) and 17 of 23 (74%) for cardiomyopathy. Of the cardiomyopathy patients 3 of 4 (75%) had a positive TL-201 scan with exercise consistent with reversible ischemia. In summary, many females with chest pain have abnormal hemodynamics despite normal coronary arteries. Use of °EF>0 as the criteria for a normal response to exercise is more specific than °EF?5 with exercise for separating normals from abnormals. A wall motion abnormality that develops with exercise can be seen with cardiomyopathy or with coronary artery disease in females. The radionuclide angiographic studies with exercise can separate normal from abnormal, but not cardiomyopathy from coronary artery disease. The positive TL-201 response with exercise in the cardiomyopathy group would suggest that a regional process could be present and only cardiac catheterization can separate cardiomyopathy from coronary artery disease.     

Refractory hypertension: definition, prevalence, and patient characteristics

Among patients with resistant hypertension (RHTN), there are those whose blood pressure (BP) remains uncontrolled in spite of maximal medical therapy. This retrospective analysis aims to characterize these patients with refractory hypertension. Refractory hypertension was defined as BP that remained uncontrolled after ≥3 visits to a hypertension clinic within a minimum 6-month follow-up period. Of the 304 patients referred for RHTN, 29 (9.5%) remained refractory to treatment. Patients with refractory hypertension and those with controlled RHTN had similar aldosterone levels and plasma renin activity (PRA). Patients with refractory hypertension had higher baseline BP (175±23/97±15 mm Hg vs 158±25/89±15 mm Hg; P=.001/.005) and heart rate, and higher rates of prior stroke and congestive heart failure. During follow-up, the BP of patients with refractory hypertension remained uncontrolled (168.4±14.8/93.8±17.7 mm Hg) in spite of use of an average of 6 antihypertensive medications, while those of patients with controlled RHTN decreased to 129.3±11.2/77.6±10.8 mm Hg. Spironolactone reduced the BP by 12.9±17.8/6.6±13.7 mm Hg in patients with refractory hypertension and by 24.1±16.7/9.2±12.0 mm Hg in patients with controlled RHTN. In patients with RHTN, approximately 10% remain refractory to treatment. Similar aldosterone and PRA levels and a diminished response to spironolactone suggest that aldosterone excess does not explain the treatment failure.     

Prosthesis-patient mismatch: definition, clinical impact, and prevention

Prosthesis-patient mismatch (PPM) is present when the effective orifice area of the inserted prosthetic valve is too small in relation to body size. Its main haemodynamic consequence is to generate higher than expected gradients through normally functioning prosthetic valves. This review updates the present knowledge about the impact of PPM on clinical outcomes. PPM is common (20-70% of aortic valve replacements) and has been shown to be associated with worse haemodynamic function, less regression of left ventricular hypertrophy, more cardiac events, and lower survival. Moreover, as opposed to most other risk factors, PPM can largely be prevented by using a prospective strategy at the time of operation.     

痴呆的定义、分类、诊断和鉴别诊断

1 痴呆的定义 痴呆是一种综合征,其定义为后天智力功能的持续性障碍,在临床上必须具备以下精神活动中的任何三个项目的障碍:言语、记忆力、视空间功能、情绪或人格和认知(抽象思维、计算、判断和执行能力等).     

Clinical and operational value of the extensively drug-resistant tuberculosis definition.

Currently, no information is available on the effect of resistance/susceptibility to first-line drugs different from isoniazid and rifampicin in determining the outcome of extensively drug-resistant tuberculosis (XDR-TB) patients, and whether being XDR-TB is a more accurate indicator of poor clinical outcome than being resistant to all first-line anti-tuberculosis (TB) drugs. To investigate this issue, a large series of multidrug-resistant TB (MDR-TB) and XDR-TB cases diagnosed in Estonia, Germany, Italy and the Russian Federation during the period 1999-2006 were analysed. Drug-susceptibility testing for first- and second-line anti-TB drugs, quality assurance and treatment delivery was performed according to World Health Organization recommendations in all study sites. Out of 4,583 culture-positive TB cases analysed, 361 (7.9%) were MDR and 64 (1.4%) were XDR. XDR-TB cases had a relative risk (RR) of 1.58 to have an unfavourable outcome compared with MDR-TB cases resistant to all first-line drugs (isoniazid, rifampicin ethambutol, streptomycin and, when tested, pyrazinamide), and an RR of 2.61 compared with "other" MDR-TB cases (those susceptible to at least one first-line anti-TB drug among ethambutol, pyrazinamide and streptomycin, regardless of resistance to the second-line drugs not defining XDR-TB). The emergence of extensively drug-resistant tuberculosis confirms that problems in tuberculosis management are still present in Europe. While waiting for new tools which will facilitate management of extensively drug-resistant tuberculosis, accessibility to quality diagnostic and treatment services should be urgently ensured and adequate public health policies should be rapidly implemented to prevent further development of drug resistance.     

Probiotics: definition,scope and mechanisms of action

For a subject area of science, medicine and commerce to be so recently defined and investigated, few can compare to probiotics for the controversy they have incited. Barely a paper is published without the use of a different definition, or challenging the most used one, or proposing a different nuance of it. The situation has become even more surreal with the European Food and Safety Authority banning the word probiotic for use on labels. The reiteration of the FAO/WHO definition by the world's leading group of probiotic experts, should provide relative consistency in the near future, but what are the causes of these aberrations? This review will discuss the rationale for the definition, and the scope of the subject area and why alternatives emerge. While mechanisms of action are not widely proven, in vitro and some in vivo experiments support several. Ultimately, the goal of any field or product is to be understood by lay people and experts alike. Probiotics have come a long way in 100 years since Metchnikoff and 10 years since their globalization, but their evolution is far from over.     

Pregnancy-associated thrombocytopenia: definition, incidence and natural history

We have sought to clarify the definition and importance of newly diagnosed thrombocytopenia in pregnant women by establishing an appropriate reference interval for the platelet count, and by observing the outcome in a cohort of thrombocytopenic pregnant women. The mean platelet count was lower in 2,155 healthy pregnant than non-pregnant women, and varied with race, but did not fall with increasing gestation, except in Black women. 101 of approximately 2,800 women became newly thrombocytopenic during pregnancy by conventional criteria (platelets less than 150 x 10(9)/l), without an apparent cause. Using the reference intervals established during the study, however, 24 of these women would not have been regarded as thrombocytopenic. No bleeding tendency was observed in the mothers or their infants. Maternal platelet counts became normal in the postnatal period. Thrombocytopenia occurring for the first time during pregnancy may be a different condition from auto-immune thrombocytopenia, and we suggest the term 'pregnancy-associated thrombocytopenia' (PAT). PAT does not appear to be epidemic; it does not threaten the fetus, but it cannot be distinguished from auto-immune thrombocytopenia in individual cases.