Using probiotics in clinical practice: Where are we now? A review of existing meta-analyses

The scientific literature has demonstrated that probiotics have a broad spectrum of activity, although often the results are contradictory. This study provides a critical overview of the current meta-analyses that have evaluated the efficacy of probiotics in physiologic and pathological conditions, such as metabolic disease, antibiotic-associated and Clostridium difficile-associated diarrhea, IBS, constipation, IBD, chemotherapy-associated diarrhea, respiratory tract infection, ventilator-associated pneumonia, NAFLD, liver encephalopathy, periodontitis, depression, vaginosis, urinary tract infections, pancreatitis, incidence of ventilator-associated pneumonia, hospital infection and stay in ICU, mortality of post-trauma patients, necrotising enterocolitis in premature infants.

Only for antibiotic- and Clostridium difficile-associated diarrhea, and respiratory tract infections the effects of probiotics are considered “evidence-based.” Concerning other fields, meta-analyses lacks to define type and biologic effect of probiotic strains, as well as the outcome in a disease state. Therefore, the results presented should be a stimulus for further studies which will provide clinical recommendations.     

Combination therapy in dyslipidemia: Where are we now?

Lowering low-density lipoprotein cholesterol (LDL-C) reduces the risk of cardiovascular disease: each 1.0 mmol/L (38.7 mg/dL) reduction in LDL-C reduces the incidence of major coronary events, coronary revascularizations, and ischemic stroke by approximately 20%. Statins are a well-established treatment option for dyslipidemia, with LDL-C reduction in the range of 27–55%.     

Renovascular hypertension in 2007: Where are we now?

Hypertension in patients with renovascular disease poses a major clinical challenge. Renal arterial disease accelerates hypertension by activation of multiple pressor systems. Although younger individuals with fibromuscular lesions often respond well to angioplasty with minor associated risks, care must be taken in cases of complex vascular anomalies, such as renal artery aneurysms. More than 85% of patients referred for revascularization have atherosclerotic renal artery stenosis; most are older patients with preexisting hypertension, diabetes, and vascular disease. The benefits of stent revascularization in this group are controversial. Antihypertensive therapy works best with drugs that block the renin-angiotensin system; however, most patients require multiple agents. Detailed analysis of the literature and small prospective trials failed to identify major benefits with renal artery angioplasty as compared with intensive drug therapy. The CORAL study and others seek to randomly assign subjects with high-grade renovascular lesions to optimal medical management with and without stenting.     

Hepatocellular adenoma: Where are we now?

Hepatocellular adenoma (HCA) is a benign hepatocellular neoplasm, commonly occurs in young women with a history of oral contraceptive use. Complications including hemorrhage and malignant transformation necessitate the need for a thorough understanding of the underlying molecular signatures in this entity. Recent molecular studies have significantly expanded our knowledge of HCAs. The well-developed phenotype-genotype classification system improves clinical management through identifying “high risk” subtype of HCAs. In this article, we attempt to provide updated information on clinical, pathologic and molecular features of each subtype of HCAs.     

Sedation in gastrointestinal endoscopy: Where are we at in 2014?

Gastrointestinal endoscopies are invasive and unpleasant procedures that are increasingly being used worldwide. The importance of high quality procedures(especially in colorectal cancer screening), the increasing patient awareness and the expectation of painless examination, increase the need for procedural sedation. The best single sedation agent for endoscopy is propofol which, due to its’ pharmacokinetic/dynamic profile allows for a higher patient satisfaction and procedural quality and lower induction and recovery times, while ma-intaining the safety of traditional sedation. Propofol is an anesthetic agent when used in higher doses than those needed for endoscopy. Because of this important feature it may lead to cardiovascular and respiratory depression and, ultimately, to cardiac arrest and death. Fueled by this argument, concern over the safety of its administration by personnel without general anesthesia training has arisen. Propofol usage seems to be increasing but it’s still underused. It is a safe alternative for simple endoscopic procedures in low risk patients even if administered by non-anesthesiologists. Evidence on propofol safety in complex procedures and high risk patients is less robust and in these cases, the presence of an anesthetist should be considered. We review the existing evidence on the topic and evaluate the regional differences on sedation practices.     

Endoscopic ultrasound in chronic pancreatitis: Where are we now?

Endoscopic ultrasonography (EUS) is well suited for assessment of the pancreas due to its high resolution and the proximity of the transducer to the pancreas, avoiding air in the gut. Evaluation of chronic pancreatitis (CP) was an early target for EUS, initially just for diagnosis but later for therapeutic purposes. The diagnosis of CP is still accomplished using the standard scoring based on nine criteria, all considered to be of equal value. For diagnosis of any CP, at least three or four criteria must be...     

Exercise stress echocardiography: Where are we now?

Exercise stress echocardiography (ESE) is a widely used diagnostic test in cardiology departments. ESE is mainly used to study patients with coronary artery disease; however, it has increasingly been used in other clinical scenarios including valve pathology, congenital heart disease, hypertrophic and dilated cardiomyopathies, athlete evaluations, diastolic function evaluation, and pulmonary circulation study. In our laboratories, we use an established methodology in which cardiac function is evaluated while exercising on a treadmill. After completing the exercise regimen, patients remain in a standing position or lie down on the left lateral decubitus, depending on the clinical questions to be answered for further evaluation. This method increases the quality and quantity of information obtained. Here, we present the various methods of exercise stress echocardiography and our experience in many clinical arenas in detail. We also present alternatives to ESE that may be used and their advantages and disadvantages. We review recent advances in ESE and future directions for this established method in the study of cardiac patients and underline the advantage of using a diagnostic tool that is radiation-free.     

Immune therapies in pancreatic ductal adenocarcinoma: Where are we now?

Pancreatic ductal adenocarcinoma(PDAC)is one of the deadliest cancers,mostly due to its resistance to treatment.Of these,checkpoint inhibitors(CPI)are inefficient when used as monotherapy,except in the case of a rare subset of tumors harboring microsatellite instability(2%).This inefficacy mainly resides in the low immunogenicity and non-inflamed phenotype of PDAC.The abundant stroma generates a hypoxic microenvironment and drives the recruitment of immunosuppressive cells through cancerassociated-fibroblast activation and transforming growth factorβsecretion.Several strategies have recently been developed to overcome this immunosuppressive microenvironment.Combination therapies involving CPI aim at increasing tumor immunogenicity and promoting the recruitment and activation of effector T cells.Ongoing studies are therefore exploring the association of CPI with vaccines,oncolytic viruses,MEK inhibitors,cytokine inhibitors,and hypoxia-and stroma-targeting agents.Adoptive T-cell transfer is also under investigation.Moreover,translational studies on tumor tissue and blood,prior to and during treatment may lead to the identification of biomarkers with predictive value for both clinical outcome and response to immunotherapy.     

Patient-reported outcomes in acute myeloid leukemia: Where are we now?

Outcomes for acute myeloid leukemia remain poor, and treatment decisions must consider not just quantity, but also quality of life (QOL). We conducted a systematic review of studies in patients with acute myeloid leukemia or high-risk myelodysplastic syndrome that incorporated patient-reported outcome (PRO) measures. PubMed and PsycINFO were searched for articles published from January 2000 through June 2016. Forty-one were relevant for our review with more published in recent years. There was considerable inter-study heterogeneity in which instruments were used, and many studies employed multiple (often overlapping) instruments. Longitudinal studies in particular suffered from both high attrition rates due to disease-related mortality as well as waning compliance with questionnaire completion. There remain significant challenges to incorporation of PROs into leukemia trials. Despite these limitations, however, well-implemented PROs can provide important information beyond objective response outcomes and highlight areas of focus for clinicians caring for patients and for future research endeavors.     

Treatment of primary aldosteronism: Where are we now?

Primary aldosteronism (PA) is an important cause of secondary hypertension, is being increasingly diagnosed and may account for more than 10% of hypertensive patients, both in primary care and in referral centers. Aldosterone excess is associated with adverse cardiovascular, renal and metabolic effects that are in part hypertension-independent. Laparoscopic adrenalectomy remains the mainstay of treatment for unilateral forms of PA, whereas medical treatment is recommended for bilateral forms of PA. However, a favourable surgical outcome depends on several factors and many patients are not suitable for this treatment. On the other hand, surgery in patients considered to have bilateral PA may contribute to better blood pressure control. In this review, established and novel strategies for the management of different types of PA are discussed.     

The concept of spondyloarthritis: Where are we now?

The term spondyloarthritis (SpA) encompasses a group of diseases characterized by inflammation in the spine and in the peripheral joints, and other clinical features such as uveitis, dactylitis, psoriasis, inflammatory bowel disease, and association with human leukocyte antigen (HLA) B27. The spectrum of SpA encompasses axial spondyloarthritis (axSpA) and peripheral spondyloarthritis including psoriatic arthritis (PsA), reactive arthritis (ReA), and inflammatory bowel disease-associated arthritis. In recent years, there has been tremendous progress in understanding the natural history and pathogenetic mechanisms underlying SpA leading to the development of effective treatments. It has become imperative to identify the disease early, and accurately, to avail patients of effective treatments in a safe manner. The development of the Assessment of SpondyloArthritis International Society (ASAS) classification criteria has been a welcome advance in this regard. This article provides a historical evolution of the concept of SpA, from the Rome Criteria to the ASAS criteria, current issues and barriers with the use of ASAS criteria, and the work that still needs to be done moving forward.     

Role of endoscopic ultrasound in vascular interventions: Where are we now?

From a mere diagnostic tool to an imperative treatment modality, endoscopic ultrasound (EUS) has evolved and revolutionized safer efficient options for vascular interventions. Currently it is an alternative treatment option in the management of gastrointestinal bleeding, primarily variceal type bleeding. Conventional treatment option prior to EUS incorporation had limited efficiency and high adverse events. The characterization and detail provided by EUS gives a cutting edge towards a holistically successful management choice. Data indicates that EUS-guided combination therapy of coil embolization and glue injection has the higher efficacy for the treatment of varices. Conversely, similar treatment options that exist for esophageal and other ectopic variceal bleeding was also outlined. In conclusion, many studies refer that a combination therapy of coil and glue injection under EUS guidance provides higher technical success with fewer recurrence and adverse events, making its adaptation in the guideline extremely favorable. Endo-hepatology is a novel disciple with a promising future outlook, we reviewed topics regarding portal vein access, pressure gradient measurement, and thrombus biopsy that are crucial interventions as alternative of radiological procedures. The purpose of this review is to provide an update on the latest available evidence in the literature regarding the role of EUS in vascular interventions. We reviewed the role of EUS in variceal bleeding in recent studies, especially gastric varices and novel approaches aimed at the portal vein.     

Bronchoscopic interventions for severe emphysema: Where are we now?

Patients with severe emphysema have limited treatment options and only derive a small benefit from optimal medical treatment. The only other therapy to have significant clinical beneficial effect in emphysema is LVRS but the perceived risk and invasiveness of surgery has fuelled bronchoscopic approaches to induce lung volume reduction. There are multiple bronchoscopic methods for achieving volume reduction in severe emphysema: EBV, airway bypass procedure, endobronchial coils, thermal (vapour) sclerosis and chemical sclerosis (sealants). Optimal patient selection is key to successful patient outcomes. This review discusses bronchoscopic approaches for emphysema treatment which has progressed through clinical trials to clinical practice.