门脉性肺动脉高压的诊断与治疗进展

门脉性肺动脉高压是伴或不伴晚期肝病患者在门静脉高压基础上出现以肺动脉压升高和肺血管阻力增加为特点的疾病。门脉性肺动脉高压显著增加患者病死率。目前尚无明确有效的治疗药物,肝移植是唯一有效的治疗手段。本文重点介绍了门脉性肺动脉高压的流行病学、发病机制、临床表现、诊断、治疗及预后情况。     

Clinical aspects of pneumonia in the elderly veteran

While atypical presentation of pneumonia in elderly patients is thought to be common, its incidence and factors predisposing to it are unknown. This study documents presenting symptoms of pneumonia in 48 patients, aged 65 or older, admitted to the medical service at a Veterans Administration Medical Center. Seventeen subjects (35%) had a classic constellation of symptoms which included both fever and cough. A chief complaint suggestive of pneumonia, defined as cough, fever, or shortness of breath, occurred in 27 subjects (56%). Five subjects (10%) had no symptoms suggestive of pneumonia even with a detailed history. Absence of a classic constellation of pneumonia symptoms correlated with advanced age (P = .0045), cognitive impairment at admission (P = .022), and baseline functional impairment (P = .028). Neither nutritional status as measured by serum albumin nor medical status as measured by number of medical problems and number of medications predicted an atypical presentation of pneumonia. Nineteen subjects (39%) did not have a documented fever, and 15 subjects (31%) did not have a leukocytosis. Absence of fever or leukocytosis did not correlate with age, number of medical problems, number of medications, cognitive status, functional status, or serum albumin. We conclude that a classic constellation of symptoms, signs and laboratory findings is frequently absent but some suggestive symptom is usually present in this population of elderly veterans with community-acquired pneumonia. Patients with advanced age, cognitive impairment at admission, and baseline functional impairment are most likely to have an atypical presentation of pneumonia.     

Clinical experience with cardiac amyloidosis

OBJECTIVE: Amyloidosis is a systemic disease potentially afflicting the heart. In this study we retrospectively studied patients presenting with major cardiac amyloidotic involvement. METHODS AND RESULTS: From 1997 until 2000, eight patients with major cardiac involvement of amyloidosis resulting in heart failure were diagnosed. All patients presented with heart failure. Diagnostic work-up, clinical, electrocardiographic, echocardiographic characteristics and treatment modalities are presented. Seven patients with acquired (both primary AL and postinflammatory AA) amyloidosis out of a total of eight patients died within one year after diagnosis, as a result of intractable cardiac failure due to both systolic and diastolic left ventricular dysfunction despite state-of-the-art medical treatment of heart failure. Only one patient with hereditary amyloidosis undergoing liver transplantation survived. CONCLUSIONS: Despite optimal medical cardiac failure treatment, acquired cardiac amyloidosis carries an ominous prognosis probably because patients are already in a very advanced stage of the disease at presentation.     

Radiofrequency ablation for incidentally identified primary intrahepatic cholangiocarcinoma

Cholangiocarcinoma is the second most common primary hepato-biliary malignancy. The majority of patients with primary hepatic tumors are not suitable candidates for resection, due to advanced stage of the disease at presentation, anatomic limitations and medical co-morbidities. At present, radiofrequency ablation (RFA) may offer an alternative, feasible and safe therapy for selected patients with hepatic tumors, who are not otherwise candidates for hepatic resection. Herein, we present the case of successful RFA in a patient with a solitary, primary intrahepatic Cholangiocarcinoma. The patient remained free of disease 24 mo after the procedure, and is still followed up. This is the first report of RFA application in the treatment of primary intrahepatic Cholangiocarcinoma.     

Locoregional surgical and interventional therapies for advanced colorectal cancer liver metastases: expert consensus statements

Selection of the optimal surgical and interventional therapies for advanced colorectal cancer liver metastases (CRLM) requires multidisciplinary discussion of treatment strategies early in the trajectory of the individual patient''s care. This paper reports on expert consensus on locoregional and interventional therapies for the treatment of advanced CRLM. Resection remains the reference treatment for patients with bilateral CRLM and synchronous presentation of primary and metastatic cancer. Patients with oligonodular bilateral CRLM may be candidates for one-stage multiple segmentectomies; two-stage resection with or without portal vein embolization may allow complete resection in patients with more advanced disease. After downsizing with preoperative systemic and/or regional therapy, curative-intent hepatectomy requires resection of all initial and currently known sites of disease; debulking procedures are not recommended. Many patients with synchronous primary disease and CRLM can safely undergo simultaneous resection of all disease. Staged resections should be considered for patients in whom the volume of the future liver remnant is anticipated to be marginal or inadequate, who have significant medical comorbid condition(s), or in whom extensive resections are required for the primary cancer and/or CRLM. Priority for liver-first or primary-first resection should depend on primary tumour-related symptoms or concern for the progression of marginally resectable CRLM during treatment of the primary disease. Chemotherapy delivered by hepatic arterial infusion represents a valid option in patients with liver-only disease, although it is best delivered in experienced centres. Ablation strategies are not recommended as first-line treatments for resectable CRLM alone or in combination with resection because of high local failure rates and limitations related to tumour size, multiplicity and intrahepatic location.     

Management of primary biliary cirrhosis: From diagnosis to end-stage disease

Primary biliary cirrhosis (PBC) is one of the most common chronic cholestatic liver diseases affecting the adult population. The clinical presentation of PBC can be diverse, ranging from the presymptomatic individual to the patient with advanced liver disease. Initial evaluation to establish diagnosis and appropriate follow-up are very important in the life-long management of these patients. The primary medical treatment in PBC should focus on reducing the rate of disease progression. To this extent, treatment with ursodeoxycholic acid has been extensively evaluated and has been shown to improve liver biochemistries and survival in patients with PBC. Secondary medical management in PBC should address the treatment of complications of chronic cholestasis, hepatic cirrhosis, and liver failure. Liver transplantation remains the only established therapeutic approach in treatment of patients with end-stage PBC and the associated complications.     

Parenteral nutrition in advanced cancer patients

Parenteral nutrition (PN) is a medical treatment aimed at providing intravenous nutrients in patients in whom gastrointestinal function is partially or totally impaired. An obvious indication of PN in advanced cancer patients is the prevention and/or treatment of malnutrition in hypo-aphagic patients with intestinal failure due to the disease itself or the consequences of antineoplastic treatments. However, PN may also improve compliance with palliative radio/chemotherapy, reduce its side effects, enhance quality of life and prolong survival. A careful evaluation of patients' clinical conditions and families' expectations is mandatory before the decision to initiate PN in ACPs is taken, in order to avoid administration of an inappropriate or even life-threatening medical treatment. Current available evidence indicates that patients expected to die earlier from the underlying tumour rather than from starvation gather no benefit from intravenous nutritional support. Although it is likely that intravenous nutrients provided to feed the patients are also utilized by cancer cells, at present there is no evidence that this translates into a clinically relevant harm to the patient. Fear of tumour growth stimulation must not be a reason for not considering parenteral nutrition in advanced cancer patients. The risk of septic, metabolic and mechanical complications has to be considered when PN support is prescribed, although a specialized and well trained medical and nursing staff may dramatically reduce complication rate. Decisions regarding treatment initiation and its possible withdrawal should be made based on the best available evidence and non on cultural and personal attitudes.     

Management of Atherosclerotic Carotid Artery Disease: A Brief Overview and Update

Extracranial carotid atherosclerotic disease has been associated with approximately 15%-20% of ischemic stroke cases and is a leading cause of mortality and disability worldwide. Medical, surgical, and endovascular therapies for the prevention of stroke from carotid disease have advanced considerably over the past quarter century. The objective of this review is to outline the clinical presentation of symptomatic carotid artery stenosis and the risk factors associated with development of carotid artery stenosis and then summarize the current evidence-based medical treatment modalities, along with available surgical and endovascular therapies.     

Use of Social Media at Cardiovascular Congresses: Opportunities for Education and Dissemination

Social Media includes different forms of online communication from Twitter, Facebook, Instagram, LinkedIn, podcasts, YouTube etc. and has advanced how information is exchanged. A notable use is engaging on Twitter at medical conferences, both for those attending the conference and the global audience who are not able to attend. It is also increasingly used as an educational tool similar to e-learning. The objective of this paper is to: 1) highlight the impact of using Twitter at cardiovascular congresses as an interactive platform for active learning as compared to passively listening to a presentation; 2) present perspectives from not only clinicians, researchers but also patients on how this information is interpreted; 3) provide recommendations for conference organizers for best practice live tweeting to share the information and knowledge beyond those in attendance; with potential for not only engagement but also educating our global community.     

Consensus statement: Palliative and supportive care in advanced heart failure

BACKGROUND: A consensus conference was convened to define the current state and important gaps in knowledge and needed research on "Palliative and Supportive Care in Advanced Heart Failure." EVIDENCE: Evidence was drawn from expert opinion and from extensive review of the medical literature, evidence-based guidelines, and reviews. CONCLUSIONS: The conference identified gaps in current knowledge, practice, and research relating to prognostication, symptom management, and supportive care for advanced heart failure (HF). Specific conclusions include: (1) although supportive care should be integrated throughout treatment of patients with advanced HF, data are needed to understand how to best decrease physical and psychosocial burdens of advanced HF and to meet patient and family needs; (2) prognostication in advanced HF is difficult and data are needed to understand which patients will benefit from which interventions and how best to counsel patients with advanced HF; (3) research is needed to identify which interventions improve quality of life and best achieve the outcomes desired by patients and family members; (4) care should be coordinated between sites of care, and barriers to evidence-based practice must be addressed programmatically; and (5) more research is needed to identify the content and technique of communicating prognosis and treatment options with patients with advanced HF; physicians caring for patients with advanced HF must develop skills to better integrate the patient's preferences into the goals of care.     

Experience and results on the surgical and medical treatment of ischaemic colitis.

OBJECTIVE: To analyse differences between patients with transient forms of ischemic colitis managed with medical treatment and those developing gangrenous forms subsidiaries of surgical treatment. MATERIAL AND METHODS: Retrospective study (1991-1998) of the ischemic colitis cases occurred in our center separating into two groups according to treatment received (A group: medical, 19 patients; B group: surgical, 10 patients). RESULTS: Hypertension mainly appear in B group being average age higher in this group than in A group (p < 0.05). Other risk factors analysed such as diabetes, cardiovascular disease, renal failure or consume of different drugs appear in similar way in both groups. In A group patients clinical presentation hematochezia is typical while B group use to start with acute abdomen associated to abdominal distension and hyperleukocytosis (p < 0.05). In group B average estance, morbidity and mortality have been higher than in A (17.4 vs 8.6 days 70 vs 5%, 40 vs 0%, respectively). CONCLUSION: Hypertension and advanced age are associated risk factors of gangrenous ischemic colitis. The classic clinical presentation of abdominal pain and hematochezia is typical in transient forms. Patients who need a surgical operation for ischemic colitis have a high morbimortality.     

Musculoskeletal tumors in childhood.

As treatment strategies improve, the ability to cure children with musculoskeletal tumors is growing. The stage of a given malignancy, representing the degree of spread of the tumor to its local surroundings or distant sites, is the best predictor of long-term survival. Unfortunately, the insidious nature of the presentation of these tumors leads to their late recognition in advanced stages. This review will present scenarios suggesting the need for consideration of malignancy in the differential diagnosis of clinical problems related to the musculoskeletal system. Pitfalls in diagnosis and therapeutic approaches will also be discussed.     

The 10-minute oral presentation: what should I focus on?

BACKGROUND: Little empirical evidence is available in the medical field defining the most important features of a scientific presentation. We sought to empirically identify what features of a scientific oral presentation experienced reviewers focus on when asked to identify the best features and areas to improve. METHODS: Observational study of 44 presenters at a scientific meeting over a 4-year period. Reviewers observed presenters and identified the best features and made suggestions for improvement using an open-ended form. We developed a coding form based on three domains: content, slides, and presentation style. Two raters blinded to the presenter then coded the comments, and disagreement was resolved by concurrent review. RESULTS: Reviewers made at least one comment about content in 42 (95.5%) of the presentations, about slides in 38 (86.4%), and about presentation style in 42 (95.5%). The most frequently extracted comments on best features of presentations in the domain "content" were identifying a key concept (43.2% of presentations) and relevance (43.2%). Similarly, best features in the domain regarding "slides" were clarity (50.0% of presentations), graphics (27.3%), and readability of the text and font size (22.7%). Finally, best features in the domain regarding "presentation style" were clarity (59.1% of presentations), pace (52.3%), voice (47.7%), engaging with the audience (43.2%), addressing questions (34.1%), and eye contact (22.7%). Various other comments were noted to improve presentations. CONCLUSIONS: Important features during oral presentations relate to specific areas of content, clear slides, and a presentation style that was well paced, engaging, and clear. Nonverbal communication is important in oral presentations.     

Primary pulmonary AIDS-related lymphoma

Extranodal involvement is common in lymphomas associated with human immunodeficiency virus infection (HIV) and acquired immunodeficiency syndrome (AIDS). However, primary pulmonary AIDS-related non-Hodgkin's lymphoma is very rare and only few reports were published in the medical literature. Clinical presentation is nonspecific, with "B" and respiratory symptoms. Also, patients were with advanced immunodeficiency at the time of diagnosis. Generally, chest radiography showed peripheral nodules or cavitary masses. Primary pulmonary lymphoma associated with AIDS is generally a high-grade B-cell non-Hodgkin lymphoma and Epstein-Barr virus is strongly associated with the pathogenesis of these tumors. We report a patient with AIDS and primary pulmonary lymphoma which clinical presentation was a total atelectasis of the left lung.     

Multidisciplinary management of early and locally advanced esophageal cancer

Clinical management of esophageal cancer is a multidisciplinary challenge. Diagnosis is associated with a high mortality and approximately 40% of patients have locally advanced disease at clinical presentation. Surgery remains one of the fundamental parts of treatment, but multimodal approaches including chemotherapy and radiation are associated with improved outcomes. This comprehensive review addresses the multidisciplinary management of early and locally advanced esophageal cancer.     

Therapeutic options and heart failure survival score predictability in an academic heart failure center: an analysis of 120 consecutive patients during a 1-year period

BACKGROUND: the incidence and prevalence of patients with advanced heart failure is increasing worldwide and the number of cardiac transplantations remains limited. AIMS: it was the aim of the study to describe our experience with the increasing number of available medical, interventional and cardiac surgery options, and to assess heart failure survival score predictability in an academic heart failure center within a 1-year follow-up. METHODS AND RESULTS: in all patients who were referred for cardiac transplant evaluation within a 12-month period between April 1998 and March 1999 at our Interdisciplinary Heart Failure and Transplant Program, our team assessed all medical interventions as well as interventional and surgical treatment options that were available, based on the clinical profile on initial presentation. In 92% of the 120 patients referred for cardiac transplantation evaluation, drug therapy could be optimized. A considerable number of patients could be subjected to an organ-preserving intervention or surgery, either PTCA (n=11), CABG (n=4), valve repair (n=7), multisite pacing (n=7), or partial ventricular resection (n=5). Only a small group of patients with the worst heart failure survival score were listed for heart transplantation (n=17) or received a ventricular assist device (n=3). CONCLUSIONS: within a contemporary cohort of advanced heart failure patients, only a small number of patients will undergo cardiac transplantation, which is predictable by the heart failure survival score. Most patients will undergo optimized medical therapy and a considerable number will be subjected to interventional or surgical treatment options.     

General advice for the international traveler.

Medical concerns of the traveling patient may be organized into pre-travel medical advice and preparation, maintenance of health and behavioral modification during travel, and post-travel diagnosis and treatment for travelers returning with illness or a significant change in their general health. Pre-travel medical advice and preparation may be done in large part by well-informed primary-care providers, although patients with special health conditions or unusually complicated or high-risk itineraries may be best referred to a travel medicine specialist. Although diagnosis and treatment of exotic and tropical diseases usually falls within the area of expertise of the infectious diseases specialist, primary physicians should be familiar with the geographic distribution and presentation of the more common of these diseases, so that appropriate referrals will be made.     

Delayed thrombolytic treatment of older patients with acute myocardial infarction.

OBJECTIVE: To determine demographic and clinical factors associated with delayed thrombolysis in patients with acute myocardial infarction. DESIGN: A retrospective cohort. SETTING: 37 Minnesota hospitals during the time periods October 1992-July 1993 and July 1995-April 1996. PATIENTS: We reviewed the medical records of 776 older patients aged 65 or older hospitalized with an admission diagnosis of acute myocardial infarction, suspected acute myocardial infarction, or rule-out acute myocardial infarction, who were treated with a thrombolytic agent. MEASUREMENT: We used multivariate logistic regression models to examine the association between selected study characteristics and time between hospital presentation and administration of thrombolytic treatment. Early thrombolysis was defined as less than 60 minutes after hospital presentation and late thrombolysis as 60+ minutes. RESULTS: Of 776 study patients, 57.5% (n = 446) received early thrombolysis. Of the remaining 330 patients receiving late treatment, 12.1% (n = 94) were thrombolyzed more than 2 hours after hospital presentation. After controlling for other factors, the odds of delayed thrombolysis among patients aged 75 or older were 1.48 compared with younger individuals (95% CI, 1.17-1.88). The odds of delayed thrombolysis among patients with severe comorbidity were 1.46 (95% CI, 1.10-1.94) compared with individuals without severe comorbidity. Predictors of early thrombolytic treatment included hospital arrival via emergency transport (ORdelay = 0.46; 95% CI, 0.34-0.63) and chest discomfort at admission (ORdelay = 0.40; 95% CI, 0.18-0.86). CONCLUSIONS: The present study indicates that patients of advanced age and with severe comorbidity are more likely to experience delayed thrombolytic treatment after hospital presentation. These are the patients who suffer the highest morbidity from acute myocardial infarction and for whom expeditious treatment may enhance therapeutic benefit.     

Management of internal fistulas in Crohn's disease

Internal fistulas occur in 5-10% of patients with Crohn's disease. The clinical presentation of each of the three main types of internal fistulas--enteroenteric, enterovaginal, and enterovesical fistulas--is important in determining the best management. Asymptomatic fistulas usually require no treatment, but fistulas that cause severe or persistent symptoms necessitate intervention. Previously regarded as a surgical condition requiring resection, some internal fistulas are amenable to a more conservative approach involving medical therapy, surgical repair, or both. So far, there have not been any prospective studies designed specifically to assess the efficacy of a medical treatment of internal fistulas, and information about treatment results is gleaned from trials in which patients with internal fistulas have been included and from retrospective reports. Drugs that have been reported to close internal fistulas partially or completely include azathioprine, 6-mercaptopurine, mycophenolate mofetil, cyclosporine A, tacrolimus, and infliximab. Reparative surgical techniques include transrectal and transvaginal mucosal advancement flaps, cutaneous advancement flap, and anal stricturectomy in combination with a rectal mucosal advancement sleeve. Prospective trials of medical therapy and combination medical and surgical therapy for internal fistulas are needed to provide evidence to support the use of these new therapeutic approaches.     

Treatment strategies for hepatocellular carcinoma in Japan

The main methods of treatment for hepatocellular carcinoma (HCC) in Japan are hepatic resection, radiofrequency ablation (RFA) and transcatheter arterial chemoembolization (TACE). Meticulous follow up is then undertaken to check for recurrence, which is treated using repeated RFA or TACE. Hepatic arterial infusion chemotherapy has been introduced as treatment for advanced HCC, and the molecular‐targeted drug sorafenib is also now available. Rigorous medical care using these treatment methods and early diagnosis mean that the prognosis for HCC in Japan is the best in the world. This paper reviews the treatment strategies for HCC in Japan.