Lung transplantation: state of the art.

Since the first long term successful single lung transplant in 1983, followed by a successful double lung transplant in 1986, lung transplantation has become established world-wide as an accepted option in the treatment of end-stage respiratory disease of various etiologies. Both procedures carry acceptable morbidity and mortality rates with the actuarial 5 year survivor rate of 80%. Single or double lung transplantation offers many advantages over heart-lung transplantation and is gradually supplanting the latter in most centers with certain exceptions. Differentiating injection from rejection continues to be a major problem but with added experience and new diagnostic tools this obstacle will be overcome.     

Somatopause: state of the art

Aging is associated with decay in the somatotroph axis, that has been considered to cause many of the catabolic sequelae of normal aging. The physiological changes that the human body undergoes during aging are similar to those observed in GH deficiency (GHD). Changes of aging are represented by increased fat mass, increased cardiovascular risk, reduced muscle mass, reduced exercise tolerance, decreased strength and impaired quality of life. Some authors conjecture that the elderly could be GH deficient and would benefit from GH treatment. However, the endocrine pattern of aging is distinct from the decrease of GH/IGF-I levels associated with hypopituitarism, although there is not sufficient evidence for a clear therapeutic role of GH treatment during somatopause. So, further studies are needed to evaluate the real benefit of somatotropic treatment in aging. This review is focused on the effects of the somatopause and summarize the potentials for a therapeutic role of the recombinant human GH (rhGH) or of GH secretagogues in aging.     

Management of spontaneous pneumothorax: state of the art.

Spontaneous pneumothorax remains a significant health problem. However, with time, there have been improvements in pathogenesis, diagnostic procedures and both medical and surgical approaches to treatment. Owing to better imaging techniques, it is now clear that there is almost no normal visceral pleura in the case of spontaneous pneumothorax, and that blebs and bullae are not always the cause of pneumothorax. In first episodes of primary spontaneous pneumothorax, observation and simple aspiration are established first-line therapies, as proven by randomised controlled trials. Aspiration should be better promoted in daily medical practice. In the case of recurrent or persistent pneumothorax, simple talc poudrage under thoracoscopy has been shown to be safe, cost-effective and no more painful than a conservative treatment using a chest tube. There are also new experimental data showing that talc poudrage, as used in Europe, does not lead to serious side-effects and is currently the best available pleural sclerosing agent. Alternatively, surgical techniques have considerably improved, and are now less invasive, especially due to the development of video-assisted thoracoscopic surgery. Studies suggest that video-assisted thoracoscopic surgery may be more cost-effective than chest tube drainage in spontaneous pneumothorax requiring chest tube drainage, although it is more expensive than simple thoracoscopy and requires general anaesthesia, double-lumen tube intubation and ventilation. Recommendations are made regarding the treatment of pneumothorax. In secondary or complicated primary pneumothorax, i.e. recurrent or persistent pneumothorax, some diffuse treatment of the visceral pleura should be offered, either by talc poudrage under thoracoscopy or by video-assisted thoracoscopic surgery. Moreover, all of these new techniques should be better standardised to permit comparison in randomised controlled studies.     

Arthroscopic synovectomy: state of the art

Arthroscopic synovectomy for first performed for haemophilic arthropathy in 1980 and was considered a major improvement over open surgical synovectomy, causing less postoperative morbidity and fewer hospitalizations, and preserving range of motion. Long-term results have shown that recurrent haemarthroses are decreased and joint function is preserved. Radiographic changes, however, suggest continued progression of the disease process. The procedure is technically demanding and requires considerable resources including skilled personnel, surgical equipment and an adequate supply of factor concentrate, all of which limit the availability of the procedure worldwide. Where this procedure fits into the treatment of chronic haemophilic synovitis depends very much on location and availability of resources. Consequently, the procedure should not be considered as the first-line approach for recurrent haemarthroses, but rather as a secondary procedure if alternative measures have failed.     

Ultrafast-acting insulins: state of the art

Optimal coverage of prandial insulin requirements remains an elusive goal. The invention of rapid-acting insulin analogs (RAIAs) was a big step forward in reducing postprandial glycemic excursions in patients with diabetes in comparison with using regular human insulin; however, even with these, the physiological situation cannot be adequately mimicked. Developing ultrafast-acting insulins (UFIs)-showing an even more rapid onset of action and a shorter duration of action after subcutaneous (SC) administration-is another step forward in achieving this goal. The need for UFIs has been gradually recognized over the years, and subsequently, a number of different approaches to cover this need are in clinical development. A rapid increase in circulating insulin levels can be achieved by different measures: modification of the primary structure of insulin molecule (as we know from RAIAs), addition of excipients that enhance the appearance in the monomeric state post-injection, or addition of enzymes that enable more free spreading of the insulin molecules in the SC tissue. Other measures to increase the insulin absorption rate increase the local blood flow nearby the insulin depot in the SC tissue, injecting the insulin intradermally or applying via another route, e.g., the lung. The development of these approaches is in different stages, from quite early stages to nearing market authorization. In time, daily practice will show if the introduction of UFIs will fulfill their clinical promise. In this review, the basic idea for UFIs will be presented and the different approaches will be briefly characterized.     

早期复极的最新研究进展

<正>半个世纪以来,心脏病学家认为早期复极(early repolarization,ER)为心电图的良性变异。但是,近期有明确证据表明,ER与特发性心室颤动(ventricular fibrillation,VF)存在有统计学意义的相关性;大型人群为基础的前瞻性研究显示,ER人群的猝死发生率明显增加,特别是无症状的年轻人,考虑到猝死的危险性,ER成为值得关注的问     

TAVI 2012: state of the art

The development of “transcatheter aortic valve implantation (TAVI)” is changing the field of cardiovascular medicine rapidly. The basic principle of TAVI is the percutaneous implantation of a bioprosthesis mounted in a metal frame. The prosthesis, which is attached to the tip of the catheter, is positioned in the native aortic valve and expanded. The first successful implantation was made by Alain Cribier in 2002. Several smaller mono- and multicenter studies later confirmed the technical feasibility of this procedure. Its true value as an important, therapeutic alternative to open heart surgery in inoperable and high-risk patients is now confirmed in large multicenter registries and by the prospective, randomized PARTNER trial. Decisive for the future acceptance of the procedure and for a possible expansion of the indication spectrum will be (1) continuous further development of the implantation technique and the prosthesis design, (2) reduction of TAVI-associated complications, (3) confirmation of the initial positive long-term results and (4) confirmation of the promising results in the treatment of surgical prosthesis dysfunctions and of patients with low to intermediate risk.     

Coronary endarterectomy: state of the art

Coronary endarterectomy (EA) allows to recanalize and bypass what appear to be an otherwise inoperable vessel. Although the application of this procedure is still controversial, there is now an increasing tendency to use the EA more frequently and recent studies confirm this trend. A variety of individualized techniques of performing coronary EA (local EA, conventional "blind" EA, open EA with coronary reconstruction, laser EA) are analyzed. Technical aspects, indications and results (operative risk, symptomatic improvement, grafts patency) of each procedure are evaluated on the basis of the current experiences. Although hospital mortality and perioperative infarction rates are moderately higher than in routine grafting, it is stressed that EA is a valuable supplement to coronary artery bypass grafting extending the indications of myocardial revascularization: a) larger number of conventionally inoperable patients can benefit from the surgical treatment; b) more complete revascularizations are possible in patients with diffuse coronary disease.     

肥胖性心肌病研究进展

<正>肥胖是一种多因素引起的慢性代谢性疾病,1948年世界卫生组织已将其列为一种疾病。根据世界卫生组织定义,正常成人体质指数(BMI)为18.5～24.9 kg/m2,BMI为25.0～29.9 kg/m2属超重,BMI≥30 kg/m2即为肥胖,2004年世界卫生组织统计全球至少4亿人达到肥胖标准[1]。肥胖者全因死     

Gallbladder imaging. The state of the art

Cholelithiasis and its sequelae are readily identified by the myriad imaging techniques available. Understanding the technical issues and correlation of specific findings with the clinical symptoms is essential for accurate diagnosis.     

Interaction between rhinitis and asthma: state of the art.

Rhinitis and asthma are very prevalent allergic disorders with comorbid features, similar risk factors, and environmental triggers. Pathophysiological processes are linked via tissue histopathology, immunologic pathway, and inflammatory mediators. Allergen challenge of the upper airway can increase lower-airway responsiveness and allergen challenge of the lower airway can lead to upper-airway inflammation. Both allergic rhinitis and asthma exert a high social and economic burden in significant loss of work and school days as well as impairment for children and adults.     

Cardiac pacing: the state of the art

Permanent cardiac pacing remains the only effective treatment for chronic, symptomatic bradycardia. In recent years, the role of implantable pacing devices has expanded substantially. At the beginning of the 21st century, exciting developments in technology seem to happen at an exponential rate. Major advances have extended the use of pacing beyond the arrhythmia horizon. Such developments include dual-chamber pacers, rate-response algorithms, improved functionality of implantable cardioverter defibrillators, combinations of sensors for optimum physiological response, and advances in lead placement and extraction. Cardiac pacing is poised to help millions of patients worldwide to live better electrically. We review pacing studies of sick-sinus syndrome, neurocardiogenic syncope, hypertrophic obstructive cardiomyopathy, and cardiac resynchronisation therapy, which are common or controversial indications for cardiac pacing. We also look at the benefits and complications of implantation in specific arrhythmias, suitability of different pacing modes, and the role of permanent pacing in the management of patients with heart failure.     

Research synthesis: the state of the art

The state of the art in research synthesis has advanced significantly in the last decade. Much of the improvement in research reviews is attributable to the application of rigorous scientific standards to the process of research synthesis. Three principal types of research syntheses are the narrative review, the replicated secondary analysis, and the meta-analysis or quantitative research synthesis. Each methodology has its strengths and weaknesses, but all have benefited from increased attention to procedural rigor. Modern methods for quantitative research synthesis have significant advantages in that they provide specific tests for the existence and consistency of relationships across studies.     

Subclinical hypothyroidism: the state of the art

Subclinical hypothyroidism (SH) is a common clinical problem, particularly in adulthood and the elderly. Its prevalence is conditioned by several etiological and risk factors. The highest age- and sex-specific rates are in women over 60. SH may be associated with manifestations of mild thyroid failure, which may reverse under levothyroxine (L-T4) therapy. The risk of progression to overt hypothyroidism is distinctly higher in cases with underlying thyroid disease. A population routine screening is not generally recommended, but screening is encouraged in high-risk groups. L-T4 therapy may be indicated in subjects with TSH levels which are repeatedly and consistently elevated (>10 microIU/ml) and may be considered in those with TSH ranging between 4.5-5.5 and 10 microIU/ml, particularly if anti-thyroid antibodies are positive and/or hypothyroid symptoms are present. Treatment should be based, at least initially, on L-T4 low doses.     

Prevention of dementias: state of the art

Dementias of late life constitute a major public health challenge. Alzheimer disease (AD) is the most common form. Epidemiological studies suggest that the use of nonsteroidal anti-inflammatory drugs, wine and coffee consumption and regular physical activity may delay onset of AD or reduce rate of progression. Preclinical research in animals and epidemiological studies in humans have shown that estrogen substitution strategies and lipid lowering statins may be beneficial. Thus, despite the lack of prospective studies and, therefore, consensus, different pharmacological strategies for persons at high risk for Alzheimer's disease are discussed.