An Evaluation of Performance after Informal Training in Endoscopic Retrograde Sphincterotomy

Endoscopic retrograde sphincterotomy (ERS) has become the treatment of choice for certain disorders of the biliary tract and pancreas. Increased need for ERS has led experienced endoscopists to seek advanced training in this highly skilled procedure, and has resulted in the development of guidelines from the American Society for Gastrointestinal Endoscopy regarding appropriate experience, skill, and training before performing ERS. This report describes the process by which an endoscopist skilled in endoscopic retrograde cholangiopancreatography, but with no prior training in ERS, acquired appropriate training. Results in the initial 75 patients attempted after training are reported and compared with previously published data. The results suggest that skill comparable to published results was attained through adherence to the American Society for Gastrointestinal Endoscopy guidelines, and that most technical failures and complications occurred early in the series. The results also reinforce the increasing role of ERS in several disorders of the biliary tract and pancreas.     

内质网应激在心肌缺血再灌注损伤中的作用

内质网应激（ERS）是细胞对内外环境变化的一种适应性反应,有助于细胞和生命个体的存活,但持续存在或过强时则最终诱发细胞凋亡。缺血,再灌注（I／R）时,钙超载及大量自由基的生成等因素诱导过度ERS导致组织损伤。缺血预处理及稳定Ca2＋稳态可激发适当的ERS,增强细胞耐受长时间缺血刺激的能力,延缓或减轻I／R造成的组织损伤。现综述ERS在缺血再灌注损伤（IRI）中的作用,并指出ERS已成为IRI防治的新靶点。     

内质网应激反应在心血管疾病中的作用

内质网应激反应是细胞对内外环境变化的一种适应性反应,有助于细胞和生命个体的存活;然而应激过度则可引起细胞凋亡,导致疾病。现综述内质网应激反应在多种心脏、血管疾病发生、发展中的作用,并指出,内质网应激反应已成为心血管疾病防治的新靶点。     

Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society

DESCRIPTION: This guideline is an official statement of the American College of Physicians (ACP), American College of Chest Physicians (ACCP), American Thoracic Society (ATS), and European Respiratory Society (ERS). It represents an update of the 2007 ACP clinical practice guideline on diagnosis and management of stable chronic obstructive pulmonary disease (COPD) and is intended for clinicians who manage patients with COPD. This guideline addresses the value of history and physical examination for predicting airflow obstruction; the value of spirometry for screening or diagnosis of COPD; and COPD management strategies, specifically evaluation of various inhaled therapies (anticholinergics, long-acting β-agonists, and corticosteroids), pulmonary rehabilitation programs, and supplemental oxygen therapy. METHODS: This guideline is based on a targeted literature update from March 2007 to December 2009 to evaluate the evidence and update the 2007 ACP clinical practice guideline on diagnosis and management of stable COPD. RECOMMENDATION 1: ACP, ACCP, ATS, and ERS recommend that spirometry should be obtained to diagnose airflow obstruction in patients with respiratory symptoms (Grade: strong recommendation, moderate-quality evidence). Spirometry should not be used to screen for airflow obstruction in individuals without respiratory symptoms (Grade: strong recommendation, moderate-quality evidence). RECOMMENDATION 2: For stable COPD patients with respiratory symptoms and FEV(1) between 60% and 80% predicted, ACP, ACCP, ATS, and ERS suggest that treatment with inhaled bronchodilators may be used (Grade: weak recommendation, low-quality evidence). RECOMMENDATION 3: For stable COPD patients with respiratory symptoms and FEV(1) <60% predicted, ACP, ACCP, ATS, and ERS recommend treatment with inhaled bronchodilators (Grade: strong recommendation, moderate-quality evidence). RECOMMENDATION 4: ACP, ACCP, ATS, and ERS recommend that clinicians prescribe monotherapy using either long-acting inhaled anticholinergics or long-acting inhaled β-agonists for symptomatic patients with COPD and FEV(1) <60% predicted. (Grade: strong recommendation, moderate-quality evidence). Clinicians should base the choice of specific monotherapy on patient preference, cost, and adverse effect profile. RECOMMENDATION 5: ACP, ACCP, ATS, and ERS suggest that clinicians may administer combination inhaled therapies (long-acting inhaled anticholinergics, long-acting inhaled β-agonists, or inhaled corticosteroids) for symptomatic patients with stable COPD and FEV(1)<60% predicted (Grade: weak recommendation, moderate-quality evidence). RECOMMENDATION 6: ACP, ACCP, ATS, and ERS recommend that clinicians should prescribe pulmonary rehabilitation for symptomatic patients with an FEV(1) <50% predicted (Grade: strong recommendation, moderate-quality evidence). Clinicians may consider pulmonary rehabilitation for symptomatic or exercise-limited patients with an FEV(1) >50% predicted. (Grade: weak recommendation, moderate-quality evidence). RECOMMENDATION 7: ACP, ACCP, ATS, and ERS recommend that clinicians should prescribe continuous oxygen therapy in patients with COPD who have severe resting hypoxemia (Pao(2) ≤55 mm Hg or Spo(2) ≤88%) (Grade: strong recommendation, moderate-quality evidence).     

The use of bio-controlled electrostimulation of the respiration in the combined modality treatment of patients with pulmonary tuberculosis]

Electric respiration stimulation (ERS) synchronized with the onset of spontaneous breathing is more effective than induced one. Introduction of the biocontrolled ERS into the treatment and prevention of respiratory complications in the postoperative period improved the effectiveness of surgical treatment of phthisiopulmonologic patients. The biocontrolled ESR is known to provide favourable results in the multimodality treatment of patients with pneumonia, chronic bronchitis and bronchial asthma.     

Elastic properties of the lung and the chest wall in young and adult healthy pigs.

Understanding of the elastic pressure/volume (Pel/V) curve is still limited in health and disease. The aim of the present study was to elucidate the Pel/V curve and elastance of the respiratory system (ERS) lung (EL) and chest wall (ECW) in healthy pigs. Six young (20.8 kg) and seven adult (58.9 kg), anaesthetized, paralysed and ventilated pigs were studied. Pel/V curves were recorded at zero end-expiratory pressure (ZEEP) and at positive end-expiratory pressure (PEEP) up to 40 cmH2O with a computer controlled ventilator during an insufflation at a low, constant flow. Pel/V curves of the respiratory system showed a complex pattern in both young and adult pigs. During the insufflation, ERS decreased, increased, fell, and increased again. A second Pel/V curve recorded immediately after the first one showed lower elastance and only one early fall in ERS. ECW fell over the initial segment and was then nearly stable. Difference between 1st and 2nd curves reflected changes in EL caused by recruitment during the 1st insufflation. At PEEP, such signs of collapse and recruitment were reduced. A strong tendency to lung collapse contributes to a complex pattern of elastic pressure/volume curves. At low volumes and distending pressures the chest wall contributes significantly to changes in respiratory system elastance.     

Stability of the EasyOne ultrasonic spirometer for use in general practice

OBJECTIVE AND BACKGROUND: Spirometry is recommended for the diagnosis and management of chronic respiratory diseases in the community. Spirometer accuracy is critical, but few general practitioners meet the American Thoracic Society and European Respiratory Society (ATS/ERS) recommendation for daily calibration. The aim of this study was to assess the accuracy and stability of a portable ultrasonic spirometer (EasyOne) that the manufacturer claims does not require regular calibration. METHODS: Six EasyOne spirometers were used in a practice-based spirometry study. Inspiratory and expiratory accuracy was checked periodically using a certified 3-L syringe. Paired calibration checks were performed using a dedicated mouthpiece assembly (spirette) and randomly selected spirettes. RESULTS: The six spirometers were used for up to 26 weeks (mean 23.9 weeks) and a total of 1041 spirometry tests and 75 syringe calibrations were performed. All inspiratory and expiratory calibration checks using a dedicated or randomly selected spirette met the ATS/ERS accuracy criterion (3.00+/-0.105 L). The mean (range) expiratory volume deviation from target volume (3.00 L) was 0.011 L (-0.06-0.09 L) using a dedicated spirette and 0.046 L (-0.09-0.10 L) using randomly selected spirettes. The deviation from target was not affected by the mean flow generated during the calibration procedure. There was no change in calibration during the study. CONCLUSIONS: This study supports the manufacturer's claim that the EasyOne spirometer maintains its calibration during routine clinical use in general practice and does not require daily calibration as specified in international spirometry guidelines.     

Difficulties identifying and targeting COPD and population-attributable risk of smoking for COPD: a population study

STUDY OBJECTIVES: Respiratory public health interventions depend on accurate identification of the target group, yet this may vary depending on the diagnostic criteria used. We therefore compared the relative performance of various international criteria in identifying COPD cases. The burden of COPD due to smoking can only be determined from population-attributable risk (PAR) studies. These studies, lacking in the COPD literature, are necessary research in support of public health initiatives for COPD. In this representative population study, we also assessed the PAR for current and ex-smokers. DESIGN: A representative biomedical population sample of 2,501 South Australians aged > or = 18 years (The Northwest Adelaide Health [Cohort] Study). COPD diagnosis and severity were determined according to various FEV1/FVC and FEV1 percentage of predicted criteria recommended by international respiratory authorities. Demographic, health behavior, and quality-of-life data were obtained by telephone interview and self-completed questionnaire. SETTING: Northwest Adelaide. MEASUREMENTS AND RESULTS: The PAR of smoking (smokers and ex-smokers) for COPD ranged from 51 to 70% depending on the diagnostic respiratory criteria used. COPD prevalence varied depending on the criteria used: American Thoracic Society, 5.4%; British Thoracic Society, 3.5%; European Respiratory Society (ERS), 5.0%; Global Initiative for Chronic Obstructive Lung Disease, 5.4%. There was also substantial disagreement in the cases identified. An alternative approach using ERS reference values one residual SD from the mean produced a COPD prevalence estimate of 6.9%, with improved level of agreement with the established respiratory criteria suggesting their potential as screening criteria. CONCLUSIONS: The COPD risks associated with smoking and ex-smoking history were quantifiable using PAR, but PAR also suggests other, yet unquantified, risks. Targeting COPD cases for public health interventions is difficult given the range of spirometry criteria and the associated high level of underdiagnosis.     

Clinical highlights from the 2011 ERS Congress in Amsterdam

This article reports on selected papers pertinent to the most important clinical problems in the field of respiratory medicine. Expert authors from the Clinical Assembly of the European Respiratory Society (ERS) have selected updated reports related to presentations given at the 2011 ERS Annual Congress, which was held in Amsterdam (the Netherlands) and attended by more than 20,000 participants. The hot topics and selected abstracts from the scientific groups of the Clinical Assembly are discussed here in the context of recent literature.     

Systematic reviews and meta-analyses on the effects of active and passive smoking on respiratory health outcomes: the SmokeHaz online resource

BackgroundActive and passive smoking increases the risk of respiratory disease in adults and children, but communication of the magnitude of these effects in a manner that is accessible and usable by public and policy makers presents a challenge. We have therefore developed a unique online resource, SmokeHaz, which summarises the effect of smoking on a range of health outcomes, focusing on respiratory diseases.MethodsWe conducted a series of definitive systematic reviews and meta-analyses of longitudinal, nested case-control, and cohort studies. We identified eligible studies using electronic databases (Medline, Embase, and Web of Science, published from 1985 to 2013), conference proceedings, websites, reference lists of reviews and studies, and through contact with experts. No language restrictions were imposed. Random effect meta-analyses were used to pool the findings. Heterogeneity was explored with subgroup analyses, and publication bias was assessed with funnel plots.FindingsWe included a total of 216 articles, none of which disclosed tobacco industry funding. Our reviews confirmed substantially increased risks of lung cancer (risk ratio 10·9, 95% CI 8·3–14·4, n=34), chronic obstructive pulmonary disease (4·0, 3·2–5·1, n=22), and asthma (1·6, 1·1–2·4, n=8) among adult smokers, though these effects were all strongly related to quantity smoked. Exposure to passive smoking significantly increased the risk of several respiratory diseases in childhood, including asthma, wheeze, lower respiratory infections, and reduced lung function, and in adults lung cancer (1·4, 1·2–1·7, n=13). In addition to these expected findings, our reviews showed that active smoking significantly increased the risk of asthma exacerbations, sleep apnoea (2·0, 1·02–3·8 n=2), and tuberculosis (1·6, 1·2–2·1, n=4), and that passive smoking increased the risk of tuberculosis in adults (1·44, 1·02–2·01, n=2).InterpretationThe findings from the systematic reviews have been translated into easily digestible content and published on the SmokeHaz website. We are now evaluating the effectiveness, usability, and accessibility of the website for the public and policy makers.FundingThe research has been independently funded by the European Respiratory Society (ERS) and has been carried out by the UK Centre for Tobacco and Alcohol Studies, with the oversight of the ERS Tobacco Control Committee. The content of the website has been approved by the Executive Committee of ERS and developed by the European Lung Foundation.     

Clinical study on respiratory muscle training for chronic respiratory failure]

The purpose of respiratory muscle training for patients with chronic respiratory failure is to improve exercise performance during daily life. Firstly, to confirm the clinical effect on respiratory muscle training, the abdominal pad method for inspiratory muscle training and abdominal pad method with expiratory resistor for both inspiratory and expiratory muscle training were simultaneously performed. Both methods were clinically useful to increase respiratory muscle power and to subjectively decrease dyspnea. Ventilatory pattern analyzed by the Konno-Mead (K-M) diagram during exercise also showed their effectiveness. Secondly, the influence of hypoxemia and hypophosphatemia, which are important factors producing respiratory muscle fatigue, was investigated in a patient with respiratory failure. (1) O2 inhalation in patients receiving home oxygen therapy was effective in terms of the endurance time and ventilatory pattern analyzed by the K-M diagram during exercise. (2) A case of hypercapnea due to hypoventilation caused by respiratory muscle fatigue developed reduced PaCO2 following correction of serum phosphate level, suggesting that hypophosphatemia is an important clinical factor producing respiratory muscle fatigue.     

内质网应激参与调节心肌缺血/再灌注损伤研究的新进展

对急性心肌梗死(AMI)患者进行再灌注治疗的同时也会带来新的损伤,被称为缺血再灌注损伤(IRI)。IRI的发生机制复杂,目前针对IRI仍没有有效的治疗方法。最近研究表明内质网应激(ERS)在IRI中发挥重要的作用,ERS有望成为减轻IRI的新靶点。了解ERS在IRI中的发生发展机制以及其与心肌细胞死亡的关系对于改善AMI患者的预后有重要的意义。     

内质网应激在慢性阻塞性肺疾病中的研究进展

内质网应激(ERS)是细胞的一种重要自我防御机制,而强烈持久的ERS可导致细胞凋亡。未折叠蛋白反应是ERS的一条重要信号通路。支气管、肺泡上皮等细胞内含多种蛋白质合成分泌旺盛的细胞类型,本身易出现ERS;目前认为ERS与慢性阻塞性肺疾病(COPD)发病机制有一定关系。本文即对ERS与COPD的相关研究作一综述,希望为COPD的治疗提供新的方向。     

Development and evaluation of a new target heart rate formula for the adequate exercise training level in healthy subjects]

Little data is available recommending the adequate exercise level for physical fitness, so we hypothesized that the anaerobic threshold (AT) point is an ideal exercise level. We aimed to determine a new target heart rate formula for the adequate exercise training level in healthy subjects. This study first developed a new formula in 405 subjects (221 males, 184 females, mean age 48.9 +/- 12.3 years). The AT was determined during cycle ergometer exercise with continuous respiratory gas measurements. The correlation of heart rate at the AT to resting heart rate, age and gender was analyzed by the multiple regression method. Based on this correlation, a new formula calculating target heart rate was established as 74.8 + 0.76 x (resting heart rate) - 0.27 x (age) + 7.3 x S (male: 0 or female: 1). This formula was then compared to Blackburn's method in 210 subjects (139 males, 71 females, mean age 44.5 +/- 14.4 years). The difference between the new target heart rate and the heart rate at the AT was significantly lower than that between the target heart rate by Blackburn's method [(220 - age) x 0.7] and the heart rate at the AT (8.8 +/- 6.3 vs 12.7 +/- 8.2 beat/min, p < 0.001). The resting heart rate and gender are important factors in determining the target heart rate for exercise. This new formula indicates the adequate exercise training level more accurately in healthy subjects.     

Histological classification of interstitial lung diseases

The 2002 ATS/ERS consensus classification of idiopathic interstitial pneumonias standardizes definitions and criteria for classification and diagnosis of idiopathic interstitial pneumonias and replaces previous classifications. Based on clinico-radiologic-pathologic criteria seven entities were defined: idiopathic pulmonary fibrosis, nonspecific interstitial pneumonia, cryptogenic organizing pneumonia, acute interstitial pneumonia, respiratory bronchiolitis-associated interstitial lung disease, desquamative interstitial pneumonia and lymphoid interstitial pneumonia. The following paper includes a brief overview of the histopathological diagnosis of these entities as compared to other diffuse interstitial pulmonary diseases and pulmonary manifestations of collagenvascular diseases.     

Ethnic Differences in the Perception of a Video Developed for a Multiethnic Diabetes Prevention Programme in South Auckland,New Zealand

Videos were developed to help increase diabetes awareness among local Maori, Pacific Islands and European communities. The Maori and Pacific Islands versions incorporated modifications to the basic content to make them more appropriate for the target audience. Lay audiences, comprising 108 Europeans, 94 Maori and 90 Pacific Islands people in 12 different sites, viewed the version of the video tailored to their ethnic group. The Maori version was also viewed by 32 Diabetes Nurse Specialists. Likert scale ratings and openended questions were used to evaluate the video. The video was rated highly by all audiences and most subjects were able to repeat the main messages of the video. Compared with Maori and Pacific Islands subjects, Europeans found the video the easiest to understand but gained the least information. Maori and Pacific Islands subjects would have preferred a longer video (> 17 minutes). Different viewing sites revealed evidence of within-ethnic-group heterogeneity. Pacific Islands subjects particularly appreciated the educational components, while Maori and Europeans were more likely to comment on presentation. Audio-visual material is perceived differently by different ethnic groups, such differences need to be addressed when embarking on diabetes awareness campaigns.     

内质网应激与肝脏疾病研究进展

内质网应激是一种重要的细胞自我防御机制,内质网应激时,首先启动生存途径,但是持续的内质网应激将启动细胞凋亡途径.肝细胞内有大量的内质网,许多肝脏疾病均与内质网应激及其介导的细胞凋亡有关,如病毒性肝炎、酒精性肝病、非酒精性脂肪性肝病、药物性肝病、急性肝衰竭、肝癌等,针对内质网应激途径来进行凋亡保护或促进凋亡以寻找新靶点药物来治疗肝脏疾病在理论上成为可能.本文将从内质网应激反应的生存途径、凋亡途径,内质网应激及其介导的细胞凋亡在肝脏疾病发病机制中的作用以及在肝病干预治疗上的意义等方面进行综述.     

Spirometry in primary care: An analysis of spirometry test quality in a regional primary care asthma program

BACKGROUND:

Primary care office spirometry can improve access to testing and concordance between clinical practice and asthma guidelines. Compliance with test quality standards is essential to implementation.

OBJECTIVE:

To evaluate the quality of spirometry performed onsite in a regional primary care asthma program (RAP) by health care professionals with limited training.

METHODS:

Asthma educators were trained to perform spirometry during two 2 h workshops and supervised during up to six patient encounters. Quality was analyzed using American Thoracic Society (ATS) 1994 and ATS/European Respiratory Society (ERS) 2003 (ATS/ERS) standards. These results were compared with two regional reference sites: a primary care group practice (Family Medical Centre [FMC], Windsor, Ontario) and a teaching hospital pulmonary function laboratory (London Health Sciences Centre [LHSC], London, Ontario).

RESULTS:

A total of 12,815 flow-volume loops (FVL) were evaluated: RAP – 1606 FVL in 472 patient sessions; reference sites – FMC 4013 FVL in 573 sessions; and LHSC – 7196 in 1151 sessions. RAP: There were three acceptable FVL in 392 of 472 (83%) sessions, two reproducible FVL according to ATS criteria in 428 of 469 (91%) sessions, and 395 of 469 (84%) according to ATS/ERS criteria. All quality criteria – minimum of three acceptable and two reproducible FVL according to ATS criteria in 361 of 472 (77%) sessions and according to ATS/ERS criteria in 337 of 472 (71%) sessions. RAP met ATS criteria more often than the FMC (388 of 573 [68%]); however, less often than LHSC (1050 of 1151 [91%]; P<0.001).

CONCLUSIONS:

Health care providers with limited training and experience operating within a simple quality program achieved ATS/ERS quality spirometry in the majority of sessions in a primary care setting. The quality performance approached pulmonary function laboratory standards.     

内质网应激在肝脏疾病中的作用研究进展

内质网是细胞内蛋白质、脂类和糖类的重要合成基地,是细胞内钙离子的储存场所,与物质运输、物质交换、解毒作用密切相关。内质网应激是细胞的一种重要自我防御机制,能提高细胞对环境变化的适应能力,但过强过久的内质网应激则会引起不可逆的细胞损伤甚至凋亡。研究发现,内质网应激与多器官多种疾病相关。肝细胞中含有大量的内质网,对内质网应激更为敏感,许多肝脏疾病如肝细胞癌、药物性肝损伤、非酒精性脂肪性肝病、肝胰岛素抵抗等的发病机制均与内质网应激有关。本文就内质网应激对各种肝脏疾病的影响作一概述。