Pulmonary complications of hepatic diseases

Severe chronic liver disease(CLD) may result from portal hypertension, hepatocellular failure or the combination of both. Some of these patients may develop pulmonary complications independent from any pulmonary pathology that they may have. Among them the hepatopulmonary syndrome(HPS), portopulmonary hypertension(PPH) and hepatic hydrothorax(HH) are described in detail in this literature review. HPS is encountered in approximately 15% to 30% of the patients and its presence is associated with increase in mortality and also requires liver transplantation in many cases. PPH has been reported among 4%-8% of the patient with CLD who have undergone liver transplantation. The HH is another entity, which has the prevalence rate of 5% to 6% and is associated in the absence of cardiopulmonary disease. These clinical syndromes occur in similar pathophysiologic environments. Most treatment modalities work as temporizing measures. The ultimate treatment of choice is liver transplant. This clinical review provides basic concepts; pathophysiology and clinical presentation that will allow the clinician to better understand these potentially life-threatening complications. This article will review up-to-date information on the pathophysiology, clinical features and the treatment of the pulmonary complications among liver disease patients.

Management of hypertensive crises in the elderly

高血压的危机比 180/120 mmHg 高是血压的举起。这些能迫切或突现，取决于结束机关损坏的存在。高血压的危机的临床的演讲在老病人是相当可变的，并且临床医生们必须怀疑非特定的症状。在 pathophysiological 的过细的知识在他们改变的老病人需要的设法的高血压的危机，药理学选择，使用的药的 pharmacokinetics，他们的副作用，和他们和另外的药的相互作用。Clevidipine， nicardipine， labetalol， esmolol，和 fenoldopam 在比较喜欢的选择在之中由于他们的功效和 tolerability 老。除非没有可得到的另外的选择， Nitroprusside， hydralazine，和 nifedipine 应该被避免，由于复杂并发症和无法预言的回答的高风险。

Blood glucose control in the intensive care unit: Where is the data?

Blood glucose control, including hyperglycemia correction, maintaining glucose at optimal level and avoiding hypoglycemia, is a challenge clinicians face every day in intensive care units (ICUs). If managed inadequately, its related mortality can increase. Prior to 2001, no relevant data from randomized, controlled studies assessing glucose control in the ICU were available. In the past 18 years, however, many clinical trials have defined criteria for managing abnormal blood glucose levels, as well as provided suggestions for glycemic monitoring. Point-ofcare blood glucose monitors have become the preferred bedside technology to aid in glycemic management. In addition, in some institutions, continuous glucose monitoring is now available. Cost-effectiveness of adequate glycemic control in the ICU must be taken into consideration when addressing this complex issue. Newer types of glycemic monitoring may reduce nursing staff fatigue and shorten times for the treatment of hyperglycemia or hypoglycemia. There are a variety of glycemic care protocols available. However, not all ICU clinicians are aware of them. The following minireview describes some of these concepts.

Chemotherapy in non-small cell lung cancer: opportunities for advancement

Locally advanced non-small cell lung cancer(NSCLC) continues to be a challenging disease to treat. With high rates of both local and distant failures, there is signiicant interest in inding more biologically active chemotherapy regimens that can contribute to reduce both failures. The phase III PROCLAIM trial, recently published in the Journal of Clinical Oncology entitled "PROCLAIM: randomized phase III trial of pemetrexed–cisplatin or etoposide–cisplatin plus thoracic radiation therapy followed by consolidation chemotherapy in locally advanced nonsquamous non-small-cell lung cancer", compared two diferent chemotherapy regimens given concurrently with radiotherapy in patients with stage III non-squamous lung cancer: pemetrexed plus cisplatin versus cisplatin plus etoposide. Both groups received consolidation chemotherapy. After enrolling 598 of planned 600 patients, the study was stopped early due to futility as no diference was seen in the primary end-point of overall survival. Since PROCLAIM was designed as a superiority trial, these results suggest that pemetrexed regimens do not ofer a clinical advantage over standard cisplatin plus etoposide. There are some subpopulations who might still beneit from pemetrexed, especially if clinicians are concerned about myelosuppression-related adverse events. Future trials are needed to investigate novel biologic agents and irradiation techniques that can result in more durable local and distant disease control in locally advanced NSCLC.

H pylori receptor MHC classⅡcontributes to the dynamic gastric epithelial apoptotic response

AIM: To investigate the role of MHC classⅡin the modulation of gastric epithelial cell apoptosis induced by H pylon infection. METHODS: After stimulating a human gastric epithelial cell line with bacteria or agonist antibodies specific for MHC classⅡand CD95, the quantitation of apoptotic and anti-apoptotic events, including caspase activation, BCL-2 activation, and FADD recruitment, was performed with a fluorometric assay, a cytometric bead array, and confocal microscopy, respectively. RESULTS: Pretreatment of N87 cells with the anti-MHC classⅡIgM antibody RFD1 resulted in a reduction in global caspase activation at 24 h of H pylori infection. When caspase 3 activation was specifically measured, crosslinking of MHC class n resulted in markedly reduced caspase activation, while simple ligation of MHC classⅡdid not. Crosslinking of MHC class n also resulted in an increased activation of the anti-apoptosis molecule BCL-2 compared to simple ligation. Confocal microscope analysis demonstrated that the pretreatment of gastric epithelial cells with a crosslinking anti-MHC classⅡIgM blocked the recruitment of FADD to the cell surface. CONCLUSION: The ability of MHC class n to modulate gastric epithelial apoptosis is at least partially dependent on its crosslinking. The crosslinking of this molecule has anti-apoptotic effects during the earlier time points of H pylori infection. This effect is possibly mediated by the ability of MHC classⅡto modulate the activation of the pro-apoptotic receptor Fas by blocking the recruitment of the accessory molecule FADD, and this delay in apoptosis induction could allow for prolonged cytokine secretion by H pylori-infected gastric epithelial cells.

Accelerated partial breast irradiation:advances and controversies

The management of localized breast cancer has changed dramatically over the past three to four decades.Breastconserving therapy,which involved lumpectomy followed by adjuvant irradiation,is now widely considered the standard of care in women with early-stage breast cancer.Accelerated partial breast irradiation(APBI),which involves focal irradiation of the lumpectomy cavity over a short period of time,has developed over the past two decades as an alternative to whole breast irradiation(WBI).Multiple APBI modalities have been developed including brachytherapy,external beam irradiation,and intraoperative irradiation.These new technigues have provided early-stage breast cancer patients with shorter treatment duration and more focused irradiation,delivering very high biological doses to the region at a high risk of failures over a much shorter treatment course as compared with conventional radiotherapy.However,the advantages of APBI over conventional radiotherapy are controversial,including a higher risk of complications reported in retrospective literature and shorter follow-up duration in the intraoperative APBI trials.Nevertheless,APBI presents a valuable alternative to WBI for a selected population of women with early-stage breast cancer.

Esophageal dilations in eosinophilic esophagitis: A single center experience

AIM:To diagnose the clinical and histologic features that may be associated with or predictive of the need for dilation and dilation related complications;examine the safety of dilation in patients with eosinophilic esophagitis(EoE).METHODS:The medical records of all patients diagnosed with EoE between January 2002 and July 2010were retrospectively reviewed.Esophageal biopsies were reexamined by an experienced pathologist to confirm the diagnosis(≥15 eos/hpf per current guidelines).Patients were divided into 2 groups:patients who did not receive dilation therapy and those who did.Demographics,clinical history,the use of pharmacologic therapy,endoscopic and pathology findings,and the number of biopsies and dilations carried out,if any,and their locations were recorded for each patient.The dilation group was further examined based on the interval between diagnosis and dilation,and whether or not a complication occurred.RESULTS:Sixty-one patients were identified with EoE and 22(36%)of them underwent esophageal dilations for stricture/narrowing.The peak eos/hpf was significantly higher in patients who received a dilation(P=0.04).Four(18%of pts.)minor complications occurred:deep mucosal tear 1,and small mucosal tears3.There were no cases of esophageal perforations.Higher peak eos/hpf counts were not associated with increased risk of complications.CONCLUSION:Esophageal dilation appears to be a safe procedure in EoE patients,carrying a low complication rate.No correlation was found between the peak of eosinophil count and complication rate.Complications can occur independently of the histologic features.The long-term outcome of EoE treatment,with or without dilation,needs to be determined.

Role of vitamin C in diabetic ketoacidosis:Is it ready for prime time?

Diabetic ketoacidosis(DKA) is life-threatening acute metabolic complication of diabetes mellitus(DM) that is characterized by acidosis, ketosis, and hyperglycemia, currently affecting mostly patients under 30 years of age with diabetes mellitus type 1. In both, DM and DKA, a pro-inflammatory state exists. This clinical entity occurs as a result of hyperglycemia-induced disturbances, resulting in an increased oxidative metabolism. For the latter reason, the use of vitamin C seems promising in DKA due to its antioxidant role in reducing the superoxide radicals that are consequence of the oxidative stress. This can decrease the proinflammatory state and avoids complications. Vitamin C, or also known as ascorbic acid, has been widely used in several illnesses, such as common cold, tissue healing, fertility, atherosclerosis, cancer prevention, immunity restoration, neuro-degenerative disease and also has been suggested to decrease the risk of DM, and this reason is giving place to believe that vitamin C can have an important role in treating diabetic complications such as DKA. In order to counteract these oxidative disturbances in DKA patients, we analyzed the current data regarding vitamin C and evaluate its role in any type treatment of this complication in the near future.

Long-term outcome of a moderately hypofractionated, intensity-modulated radiotherapy approach using an endorectal balloon for patients with localized prostate cancer

Background:Technical advances in radiotherapy delivery have simultaneously enabled dose escalation and enhanced bladder and rectal sparing.However,the optimal radiation fractionation regimen for localized prostate cancer is unclear.Laboratory and clinical evidence suggest that hypofractionation may improve the therapeutic ratio of radiotherapy.We report our institutional outcomes using moderately hypofractionated,intensity-modulated radio-therapy(IMRT),and an endorectal balloon,with emphasis on long-term biochemical control and treatment-related adverse events in patients with localized prostate cancer.Methods:Between January 1997 and April 2004,596 patients with cT1-T3 prostate cancer underwent IMRT using a moderate hypofractionation regimen(76.70 Gy at 2.19 Gy/fraction)with an endorectal balloon.Using D’Amico clas-sification,226(37.9%),264(44.3%),and 106(17.8%)patients had low-,intermediate-,or high-risk disease,respectively.The majority of intermediate-and high-risk patients received androgen deprivation therapy.Biochemical relapse-free survival(bRFS)was evaluated using 2005 Phoenix criteria and estimated using the Kaplan-Meier method.Results:The median follow-up was 62 months.Overall 5-and 10-year bRFS rates were 92.7%and 87.7%.For low-,intermediate-,and high-risk patients,the 5-year bRFS rates were 96.9%,93.3%,and 82.0%,respectively;the 10-year bRFS rates were 91.4%,89.3%,and 76.2%,respectively.Prostate-specific antigen,Gleason score,and T stage were significant predictors of bRFS(all P<0.01).The 5-year rates of severe(≥Grade 3)adverse events were very low:1.2%for gastrointestinal events and 1.1%for genitourinary events.Conclusions:Long-term outcomes after moderately hypofractionated IMRT are encouraging.Moderate hypofrac-tionation represents a safe,efficacious,alternative regimen in the treatment of localized prostate cancer.

对局限性前列腺癌患者采用直肠内球囊中度低分割调强放射治疗的长期结局

背景与目的放射治疗的技术进步使兼顾剂量递增和提升膀胱和直肠保留成为可能。然而,对于局限性前列腺癌的最佳辐射剂量分割方案尚不清楚。实验室和临床证据表明,低分割可提高放疗的治疗率。在此报道我们医院采用中度低分割调强放疗(intensity?modulated radiotherapy,IMRT)和直肠内球囊对局限性前列腺癌患者的治疗结局,重点关注患者的长期生化控制和治疗相关不良事件。方法从1997年1月到2004年4月,596例c T1–T3前列腺癌患者使用带直肠内球囊的中度低分割方案(76.70 Gy,2.19 Gy/次)进行IMRT。根据D'Amico分类低风险、中风险或高风险患者分别226(37.9%)例、264(44.3%)例和106(17.8%)例。大多数中、高风险患者接受雄激素剥夺治疗。使用2005年Phoenix标准评估无生化复发生存(biochemical relapse?freeSurvival,bRFS),并使用Kaplan?Meier法进行估算。结果中位随访时间为62个月。总的5年bRFS和10年bRFS率分别为92.7%和87.7%。低风险、中风险和高风险患者的5年bRFS率分别为96.9%、93.3%和82.0%,10年bRFS率分别为91.4%、89.3%和76.2%。前列腺特异性抗原、Gleason评分和T分期是bRFS的重要预测因子(均P<0.01)。重度(≥3级)不良事件的5年发生率非常低:胃肠道不良事件和泌尿生殖系统不良事件的发生率分别为1.2%和1.1%。结论中度低分割IMRT后的长期结局令人鼓舞。中度低分割是治疗局限性前列腺癌的安全、有效的替代方案。