Three-dimensional echocardiography: a new paradigm shift

Significant advances in three-dimensional echocardiography (3DE) have made this modality a powerful diagnostic tool in the cardiology clinic. It can provide accurate and reliable measurements of chamber size and function. In addition, 3DE offers novel views and comprehensive anatomic definition of valvular and congenital abnormalities by rendering 3D contoured images of the structures. It is also useful in monitoring the effectiveness of surgical or percutaneous transcatheter interventions. With demonstrations of efficacy in various clinical settings, 3DE has become a complementary part of the routine diagnostic armamentarium. However, 3DE is regarded as simply a tool for 3D volume or image rendering. If we confine the role of 3DE to this, it will remain a complementary tool to two-dimensional echocardiography (2DE) in the future. Three-dimensional echocardiography has roles beyond 3D volume or image rendering. Three-dimensional echocardiography can acquire a full volume dataset in a single shot, and with combined use of the multiplanar reconstructive mode, it can provide anatomically well-defined 2D planes from the full volume dataset. Hence, by omitting routine 2DE work, 3DE may save time for image acquisition and allow more precise and reproducible review or measurement. Taking this perspective into account, 3DE can be a suitable modality for use as a substitute for 2DE in daily practice. With further advances of 3DE and development of a unified review system capable of display and geometrical assessment of 2D as well as 3D images, 3DE will represent a new paradigm shift in echocardiographic examination in the future.     

Bayesian analysis: a new statistical paradigm for new technology

Full Bayesian analysis is an alternative statistical paradigm, as opposed to traditionally used methods, usually called frequentist statistics. Bayesian analysis is controversial because it requires assuming a prior distribution, which can be arbitrarily chosen; thus there is a subjective element, which is considered to be a major weakness. However, this could also be considered a strength since it provides a formal way of incorporating prior knowledge. Since it is flexible and permits repeated looks at evolving data, Bayesian analysis is particularly well suited to the evaluation of new medical technology. Bayesian analysis can refer to a range of things: from a simple, noncontroversial formula for inverting probabilities to an alternative approach to the philosophy of science. Its advantages include: (1) providing direct probability statements—which are what most people wrongly assume they are getting from conventional statistics; (2) formally incorporating previous information in statistical inference of a data set, a natural approach which we follow in everyday reasoning; and (3) flexible, adaptive research designs allowing multiple looks at accumulating study data. Its primary disadvantage is the element of subjectivity which some think is not scientific. We discuss and compare frequentist and Bayesian approaches and provide three examples of Bayesian analysis: (1) EKG interpretation, (2) a coin-tossing experiment, and (3) assessing the thromboembolic risk of a new mechanical heart valve.     

Chronic kidney disease-mineral-bone disorder: a new paradigm

Disturbances in mineral and bone metabolism are prevalent in chronic kidney disease (CKD) and an important cause of morbidity, decreased quality of life, and extraskeletal calcification that have been associated with increased cardiovascular mortality. These disturbances have traditionally been termed renal osteodystrophy and classified on the basis of bone biopsy. Kidney Disease: Improving Global Outcomes (KDIGO) recently sponsored a Controversies Conference to evaluate this definition. The recommendations were that (1) the term renal osteodystrophy be used exclusively to define alterations in bone morphology associated with CKD and (2) the term CKD-mineral and bone disorder (CKD-MBD) be used to describe the broader clinical syndrome that develops as a systemic disorder of mineral and bone metabolism as a result of CKD. CKD-MBD is manifested by an abnormality of any one or a combination of the following: laboratory-abnormalities of calcium, phosphorus, PTH, or vitamin D metabolism; bone-changes in bone turnover, mineralization, volume, linear growth, or strength; and calcification-vascular or other soft-tissue calcification. The pathogenesis and clinical manifestations of these components of CKD-MBD are described in detail in this issue of Advances in Chronic Kidney Disease.     

Dual-console robotic surgery: a new teaching paradigm

Robotic surgery has emerged as an alternative option in minimally invasive gynecologic surgery. The development of the dual-console da Vinci Si Surgical System^® has enabled modification of the training atmosphere. We sought to investigate operative times and surgical outcomes while operating with the dual-console model in a training environment for our first fifty cases. We identified the first fifty patients who underwent robot-assisted total hysterectomy (TRH), with or without bilateral salpingo-oophorectomy (BSO), with or without pelvic and para-aortic lymph node dissection (PPALND), by use of the dual-console robotic system. Records were reviewed for patient demographics and surgical details. All surgery was conducted using the dual-console system and performed by staff physicians and fellows. Operative time was calculated from robotic docking until completion of the procedure. Cases were identified from November 2009 through July 2010. Mean age was 56.2 years (SD 13.35, 95 % CI 52.46–59.86). Mean BMI was 29.5 (SD 7.67, 95 % CI 27.35–31.61). Seventy-eight percent of these patients were considered overweight, including 12 defined as obese (BMI 30–34.9) and 10 patients classified as morbidly obese (BMI ≥ 35). Surgery completed included PPALND alone (n = 1); radical hysterectomy (n = 1); TRH only (n = 3); TRH/BSO (n = 25); and TRH/BSO/PPALND (n = 20). Mean total operating room time was 188.8 min (SD 55.31, 95 % CI 173.45–204.11). Mean total surgical time for all cases was 118.1 min (SD 44.28, 95 % CI 105.87–130.41). Two vascular injuries were encountered, with one requiring conversion to laparotomy. These results compare favorably with historically reported outcomes from single-console systems. Utilizing the dual-console enables use of an integrated teaching and supervising environment without compromising operative times or patient outcomes.     

Home dialysis first: a new paradigm for new ESRD patients

Patients with end-stage renal disease (ESRD) were treated with either in-center hemodialysis (ICH) or one of the modes of home-based dialysis (HBD)-- peritoneal dialysis (PD) or home hemodialysis (HHD). Home-based dialysis modes showed better outcomes than ICH (PD for the first 2-3 years and HHD for the long-term). Home PD has become more attractive with overnight cyclers for PD and the use of home helpers. Home dialysis (PD or HHD) offers a high quality of life and a high degree of independence and is financially attractive. This review will propose a paradigm shift in the initial form of dialysis offered to new patients with ESRD: instead of selecting between in-center dialysis and PD, patients after they are advised of the advantages of dialysis at home (either PD or HHD) should be offered a choice between dialysis at home (PD or HHD) or in hospital. We will review the advantages of home-based dialysis and the arguments for this simple but vital change in the process by which new patients requiring dialysis choose their treatment option.     

Home dialysis as a first option: a new paradigm

Traditionally, the initial choice of dialysis for patients with end stage renal disease (ESRD) has been in-center hemodialysis (HD) or peritoneal dialysis (PD). Usually, the choice between these (PD vs. HD) has been based on the characteristics of the dialysis techniques. Obviously the choice of peritoneal dialysis implied dialysis at home, but its geographic location has been only a secondary consideration. Peritoneal dialysis has evolved as a dependable mode that gives good outcomes. This method has become more attractive with the option of overnight cyclers and the recent use of home helpers in some jurisdictions. At the same time the interest in home hemodialysis was rekindled by reports of good outcomes with short daily or nocturnal hemodialysis. Home dialysis (PD or HD) offers high quality of treatment, a high degree of patient independence, and is financially attractive. Therefore, we propose a change in our approach to the choice of the initial form of dialysis for patients with ESRD. Instead of choosing between HD and PD we should present the new patients the advantage of dialysis at home and instead of asking them to choose between peritoneal dialysis or hemodialysis, they should be offered the option to choose between dialysis at home (PD or HD) or in-hospital. This paper will review the advantages of the home-based dialysis methods and the arguments for this simple but vital change in the process of choosing the method of dialysis.     

Stem cells: a new paradigm in medical therapeutics

Even though the stem cells have been studied for decades, only during the past few years has there been an overwhelming proliferation of publications covering isolation, cultivation and utilization of the body's master cells. This paper attempts to summarize the recent studies in the field of stem cells. A number of studies have reported the existence of multipotent stem cells in the cord, cord blood, placenta, bone marrow, brain, heart, teeth, skin, liver, hair follicles and many other tissues and organs, giving rise to cell types other than their tissue of origin. Increased therapeutic use of stem cells has resulted in scientific methods of collection, testing, processing and storage of these cells, with minimal cell damage and differentiation. Cell expansion, bioreactors and tissue engineering are employed extensively to improve the cell dose and outcome. Stem cell infusion, transplantation and implantation are accepted curative therapies for many malignant and non-malignant conditions. Stem cell therapies also provide alternative solutions for the repair and regeneration of various tissues and organs. There has been a dramatic improvement in the understanding of immunosuppressive properties of stem cells on various immune cell types. Stem cells are found to secrete angiogenic cytokines that increase neovascularization. They bring the promise of curing a disease state as these cells normally regenerate tissues in a healthy organism. Stem cell transplantation, in isolation or in combination with other procedures, has been found to be effective. Stem cell therapy is also seen as a possible alternative for the treatment of different diseases such as juvenile diabetes, amyotrophic lateral sclerosis, cerebral palsy, stroke, spinal cord injury and Parkinson's disease. Regenerative medicine using human stem cells is one of the new and promising fields for treating various intractable diseases and damaged organs.     

Laser face-lifts: a new paradigm in face-lift surgery

Laser-assisted liposuction has been successfully applied to remove fat and contract skin in nonfacial areas. This study evaluated the efficacy and safety of this technique in the face. Patients ( N?=?40) requesting improvement and a shorter recovery time received one of four laser face-lift (LFL) procedures. The target area was divided into ~15 squares, each around 5?×?5 cm. Each square was treated individually by laser-assisted liposuction to surface temperature end points of 38°C to 40°C. Anatomic areas treated included the submentum, jowls, neck skin, jaw line, cervicomental angle, oral commissures, and nasolabial grooves. Wavelengths were 1064 nm and 1319/1320 nm. Patients returned to their normal lifestyle within 6 to 7 days after treatment. Patient satisfaction was generally higher than that seen in patients receiving a conventional face-lift. Adverse events were limited to burns in two patients. The LFL is a less invasive treatment with acceptable efficacy, reduced downtime, shorter recovery, and lower cost compared with the traditional face-lift.