A Canadian Working Group report on fecal microbial therapy: microbial ecosystems therapeutics

A working group from across Canada comprised of clinician and basic scientists, epidemiologists, ethicists, Health Canada regulatory authorities and representatives of major funding agencies (Canadian Institutes of Health Research and the Crohn's and Colitis Foundation of Canada) met to review the current experience with fecal microbial therapy and to identify the key areas of study required to move this field forward. The report highlights the promise of fecal microbial therapy and related synthetic stool therapy (together called 'microbial ecosystems therapeutics') for the treatment of Clostridium difficile colitis and, possibly, other disorders. It identifies pressing clinical issues that need to be addressed as well as social, ethical and regulatory barriers to the use of these important therapies.     

Future research directions in asthma: an NHLBI Working Group report

Over the last 20 years, the prevalence of asthma has nearly doubled and now affects 8-10% of the population in the United States. Asthma also remains a major illness in terms of morbidity and suffering, and is the leading cause of hospitalizations in children under 15 years of age. Because asthma poses a lifelong burden to patients and society, efforts to increase the understanding of its pathogenesis are a key factor leading to its control and cure. Consequently, the National Heart, Lung, and Blood Institute (NHLBI) convened a Working Group of extramural experts, entitled "Future Research Directions in Asthma," on April 9-10, 2003, to identify research areas of greatest promise and opportunity in the field of asthma. The priority areas identified for research in asthma include: (1) innate immunity, adaptive immunity, and tolerance; (2) mechanisms and consequences of persistent asthma and asthma exacerbations; (3) airway remodeling: clinical consequences and reversibility (clinical relevance and resolution); (4) genetics/gene-environment interactions, pharmacogenetics; (5) intervention/prevention/therapeutics; and (6) vascular basis of asthma.     

Geriatric hypertension: the growing use of calcium-channel blockers

The recognition of essential hypertension as a heterogeneous entity mandates that therapy be individualized according to the subset of hypertension that characterizes each patient. Choosing the most appropriate therapeutic regimen in elderly hypertensives is complicated by a greater susceptibility to side effects from medications, and by concomitant diseases. Calcium-channel blockers address the pathophysiologic mechanisms of generic hypertension, thus providing clinicians with more specific pharmacologic tools for treating elderly hypertensives. In addition, these agents will avoid many of the side effects of other antihypertensive agents and can ameliorate certain concomitant diseases.     

Diagnosis of prostatic intraepithelial neoplasia: Prostate Working Group/consensus report

High-grade prostatic intraepithelial neoplasia (PIN) is the most likely precursor of prostatic carcinoma. PIN has a high predictive value as a marker for carcinoma, and its identification in biopsy specimens warrants repeat biopsy for concurrent or subsequent carcinoma. The only methods of detection are biopsy and transurethral resection; PIN does not significantly elevate serum PSA concentration or its derivatives, nor does it induce a palpable mass, and cannot be detected by ultrasound. Androgen deprivation therapy decreases the prevalence and extent of PIN, suggesting that this form of treatment may play a role in chemoprevention. Radiation therapy is also associated with a decreased incidence of PIN.     

Geriatric hypertension therapy: a guide to cost-effectiveness

The traditional, stepped-care approach to the treatment of hypertension has been challenged by the introduction of new and more expensive medications. Because hypertensive patients include those who can least afford high-priced medication, such prescribing patterns may result in noncompliance and, further, may cause patients to switch to physicians or managed-care systems more considerate of their economic needs. Physicians should therefore consider cost-effectiveness in treatment of hypertensive patients.     

Geriatric hypertension controversies: uses of newer agents

Elderly patients as a group have a less favorable response to beta blockers than younger patients do. However, there are patients who do respond, and associated conditions that can be treated with beta blockers (especially angina pectoris and postmyocardial infarction prophylaxis) are common in the elderly. The place of the calcium channel blockers in an antihypertensive regimen is not clear; they can be used alone, but their long-term efficacy is probably increased by concomitant diuretic treatment.     

Geriatric hypertension of renovascular origin: diagnosis and management

Atherosclerotic occlusion of the renal arteries is the predominant cause of renovascular hypertension in the elderly. Medical therapy is appropriate when blood pressure is easily controlled and renal function remains stable. Percutaneous transluminal renal angioplasty is suitable for selected patients with non-ostial, unilateral lesions, but surgical revascularization currently offers the best interventive results for both hypertension and preservation of renal function in elderly patients with atherosclerotic renovascular disease.     

Geriatric hypertension: aggressive therapy and its physiologic rationale

At any given age, the chance of experiencing a cardiovascular event within the next 5 years increases with the levels of systolic and diastolic BP. Carefully administered antihypertensive therapy has the potential for decreasing the morbidity and mortality of large numbers of elderly patients who have diastolic or mixed hypertension.     

Geriatric hypertension: antihypertensive therapy in coronary artery disease

Systemic hypertension is a common clinical problem in the elderly. There is emerging evidence to suggest that with careful utilization of antihypertensive drugs, blood pressure can be lowered in the elderly population. Whether isolated systolic hypertension should be treated aggressively remains an unanswered question despite the evidence that systolic hypertension can cause certain cardiovascular complications. An elderly patient with hypertension and concomitant coronary artery disease merits proper blood pressure control with appropriate drugs to prevent progression of coronary disease. The therapeutic objective is not only to lower the blood pressure but to accomplish this goal with drugs which are likely to have a favorable effect on coronary artery disease. Changing trends in the drug therapy of hypertension indicate that calcium antagonists and beta-blocking drugs offer a therapeutic advantage in elderly hypertensive patients with coronary artery diseases.     

Mild cognitive impairment--beyond controversies, towards a consensus: report of the International Working Group on Mild Cognitive Impairment

The First Key Symposium was held in Stockholm, Sweden, 2-5 September 2003. The aim of the symposium was to integrate clinical and epidemiological perspectives on the topic of Mild Cognitive Impairment (MCI). A multidisciplinary, international group of experts discussed the current status and future directions of MCI, with regard to clinical presentation, cognitive and functional assessment, and the role of neuroimaging, biomarkers and genetics. Agreement on new perspectives, as well as recommendations for management and future research were discussed by the international working group. The specific recommendations for the general MCI criteria include the following: (i) the person is neither normal nor demented; (ii) there is evidence of cognitive deterioration shown by either objectively measured decline over time and/or subjective report of decline by self and/or informant in conjunction with objective cognitive deficits; and (iii) activities of daily living are preserved and complex instrumental functions are either intact or minimally impaired.     

Geriatric hypertension controversies (Part I): Initial Tx

The assumption that reducing blood pressure with drugs will be harmful or intolerable in older patients is not supported by treatment trials that have been reported to date. Patients treated nonpharmacologically need to be followed as closely as if they were receiving drug treatment.