走出对心力衰竭"常规治疗"认识的误区

近年来 ,慢性收缩性心力衰竭 (心衰 )的治疗概念有了根本性的转变 ,即从短期的、血液动力学/药理学措施转变为长期的、修复性策略 ,目的是改变衰竭心脏的生物学性质。传统的心衰治疗一贯是针对心衰的血液动力学异常 ,应用正性肌力药增强心肌收缩力 ,应用利尿剂和血管扩张剂减轻心脏负荷。因而 ,“强心、利尿、扩血管”一直被认为是经典的“心衰常规治疗”。然而 ,大量有对照的、随机双盲临床试验的结果却表明正性肌力药和单纯的血管扩张剂虽可产生短期的血液动力学效应 ,但长期治疗却增加死亡率和病残率。其中 ,地高辛是惟一的不增加心衰死…     

美国"甲状腺结节和分化性甲状腺癌诊断治疗指南"解读(Ⅰ)

近年来甲状腺结节和肿瘤的诊断治疗发生了很大变化，美国甲状腺学会根据近10年来新的循证医学证据，在Thyroid杂志2006年第1期发表了《Management Guidelines for Patients with Thyroid Nodules and Differentiated Thyroid Cancer》。该诊断治疗指南也是对1996年所发表指南的更新。主要内容包括甲状腺结节的诊断与处理，分化性甲状腺癌的初始治疗及长期随访与治疗。     

治疗心力衰竭的循证医学进展

心力衰竭(心衰)至今仍是心血管疾病重要致死的终极病变,为了让读者能了解这方面近年的进展,我们在2005年美国和欧洲的心衰治疗指南基础上,回顾关于心衰的临床试验和相关循证医学治疗概况.     

生活质量在肿瘤治疗疗效评价中的应用

随着医学模式的转变，人们将生命的目标从追求生存的数量转为生存的质量，生活质量被广泛地应用到医学领域中，对肿瘤的治疗，提高患者的生活质量已成为主要目的之一。现代医学治疗肿瘤的疗效评价标准在强调生活质量的今天，已显出它的弊端。因此，将生活质量的评价引入肿瘤治疗领域，有助于解决治疗疗效巾无法客观评价的问题。     

中国成人糖尿病肾脏疾病医学营养治疗专家共识

糖尿病肾脏疾病(diabetic kidney disease, DKD)是糖尿病主要微血管并发症之一, 表现为持续性尿白蛋白排泄率增加和(或)肾小球滤过率进行性下降, 最终发展为终末期肾脏疾病(end stage renal disease, ESRD), 严重影响患者健康及生活质量。营养不良在DKD中较为常见, 可显著增加糖尿病患者全因死亡风险。医学营养治疗(medical nutrition therapy, MNT)可延缓DKD进展、降低ESRD比例, 还可防治DKD导致的营养不良或蛋白质能量消耗。中华医学会内分泌学分会为制定符合中国DKD患者需求的MNT规范, 组织专题讨论并制定本共识, 旨在为临床工作者提供基于证据的DKD个体化MNT指导, 进而延缓DKD进展、提高生存率。     

系统性红斑狼疮的循证医学治疗

系统性红斑狼疮（SLE）临床表现复杂，治疗原则上强调早期诊断和早期治疗，以避免或延缓不可逆的组织脏器的损害。根据病情的严重度和活动情况，拟定个体化的治疗方案，定期复查，监测药物副作用，病情控制后维持治疗。     

正值"复合"(Hybrid)技术的时代

随着医学技术的不断进步，近50年来心血管病的治疗手段日新月异，而“患者利益至上”这一原则却是永恒不变的。所有患者都渴望一种最适合于自己的、创伤小、疗效佳的治疗手段。     

中国成人偏头痛预防性治疗药物临床对照试验专家共识

偏头痛是最常见的失能性原发性头痛, 疾病负担沉重。近年来, 国际上开展了诸多偏头痛预防性新药的临床试验, 显著推动了偏头痛治疗的快速进展。我国偏头痛治疗的临床试验尚处于起步阶段, 为促进和规范我国偏头痛预防性治疗的临床对照试验, 提供临床试验设计、实施和评价方面的方法学指导, 中华医学会神经病学分会头痛协作组借鉴国际头痛协会偏头痛临床研究的新进展, 并结合我国偏头痛临床研究实际情况, 制定了中国成人偏头痛预防性治疗药物临床对照试验专家共识。     

糖尿病药物治疗理念变迁

长期以来,一直认为强化降糖只能改善糖尿病的微血管并发症,不能改变糖尿病患者的心血管结局。因此,国内外指南均以糖化血红蛋白（HbA 1c）达标制定糖尿病药物治疗路径。研究表明,钠-葡萄糖共转运蛋白2抑制剂和胰高糖素样肽-1受体激动剂具有显著改善糖尿病患者的心肾结局的作用,糖尿病治疗理念发生了根本性变化,即以控...     

Association between medical comorbidity and treatment outcomes in late-life depression

OBJECTIVES: Previous studies have demonstrated an association between major depression and physical disability in late life. The objectives of this study were to examine the relationship between specific medical illnesses and the outcomes of treatment for late-life depression. DESIGN: The study was a longitudinal assessment of medical illness, depression, and disability. Patients were assessed during an initial inpatient psychiatric hospitalization and 3 months postdischarge. SETTING: All patients were initially evaluated after admission to one of 71 inpatient psychiatric treatment facilities. PARTICIPANTS: A sample of 671 older patients who received inpatient treatment for depression was evaluated at entry into the hospital and 3 months after discharge. MEASUREMENTS: Depressive symptoms were measured using the Geriatric Depression Scale. Disability was measured using the instrumental activities of daily living scale and the Medical Outcomes Study 36-item short form. Medical illness was assessed using the medical illness checklist. RESULTS: As previously reported, physical disability and the total number of medical illnesses were significantly related to change in depressive symptoms. In this study, we find that arthritis, circulatory problems, a speech disorder, or a skin problem, but not other general medical conditions, were related to a worse outcome with respect to depression symptoms. The effect of these problems was statistically and clinically significant. After controlling for pretreatment disability, arthritis and skin problems continued to predict a worse outcome. However, the apparent effect of each of these conditions was mediated by the residual disability after treatment. CONCLUSION: The results of this study support the hypothesis that certain somatic disorders play a role in the treatment response of late-life depression and suggest that the effect of specific illnesses on depression may be mediated by the presence of functional disability.     

老年人肺结核强化治疗期肝功能情况分析

目的探讨老年肺结核强化治疗期肝功能的改变。方法回顾性分析1998~2000年住院60岁以上老年肺结核强化治疗期肝功能出现异常107例(19.96%),同期60岁以下的中青年肺结核患者强化治疗期肝功能异常发生率为5.61%,且多发生在15~45天之间。结论老年肺结核患者,特别是合并有肝病患者,易发生肝功能异常。     

Medical treatment of heart failure: The Canadian Cardiovascular Society's Consensus Conference revisited

Summary The report of the Canadian Cardiovascular Society's Consensus Conference on the diagnosis and management of heart failure was published in 1994. Focusing on the chronic medical treatment of patients with systolic left ventricular dysfunction, we summarize and update the consensus recommendations in the light of the results of several more recent studies. While the positive treatment recommendations are still fully valid or even reinforced by these new data, a somewhat more liberal use of beta-blockers, amiodarone, and newer calcium channel blockers seems justified.     

Outcomes after medical and surgical treatment of diverticulitis: a systematic review of the available evidence

There is still controversy regarding the appropriate management of diverticulitis of the colon in cases when both surgical and conservative treatment may be an option. We performed a systematic review of the available evidence regarding the outcomes after medical and surgical treatment of diverticulitis from studies published after 1980 and indexed in the PubMed database. We included original studies that reported comparative data for at least one outcome in medically- and surgically-treated patients with transverse or left colon diverticulitis. The main outcomes of interest were mortality, morbidity, and recurrence of diverticulitis after medical or surgical treatment. There were 21 studies fulfilling our inclusion criteria out of 1360 initially identified as possibly relevant. More patients were treated conservatively in the included studies compared to emergency surgery (24 862 vs 6504). Emergency surgery was the main option for patients with severe complications of diverticular disease, including peritonitis. In most studies, in-hospital mortality for patients treated surgically was generally higher than that of patients treated medically, whereas there were insufficient comparative data regarding mortality during follow up. However, readmission to the hospital due to diverticular disease during follow up was more common in the group of patients treated conservatively compared to those treated surgically (4358/23 446 [18.6%]vs 22/359 [6.1%]). Conservatively-treated patients, with a first or second episode of diverticulitis, required surgery for recurrent disease during follow up in a maximum of 45% of cases, with larger studies reporting percentages lower than 11%. It should be emphasized that medical and surgical treatments have not ever been compared in a randomized controlled trial in patients with diverticulitis (without generalized peritonitis that is a surgical emergency). Although medical treatment results in more readmissions due to recurrence, it may be reasonable to avoid surgical therapy in the vast majority of patients with acute diverticulitis. It is unclear what the best treatment option is for younger patients (<50 years), namely whether elective surgery should be considered with the first episode of diverticulitis.     

Stereological evaluation of treatment response in patients with non-resectable hepatic alveolar echinococcosis using computed tomography via the Cavalieri method.

INTRODUCTION: The purposes of this study were to describe and adapt the relevant methods of computed tomography (CT) and stereology to estimate parasitic volume in the liver, to compare the efficiency of benzimidazole treatment in hepatic alveolar echinococcosis (AE), and to determine whether the response rates measured by the stereological method are correlated with those measured by simple volumetric measurements (SVM). METHODS: Nine eligible patients with non-resectable AE were included in the study. By using their abdominal CT at the baseline and after a year of treatment, treatment responses of the cases were evaluated both by the stereological method via a software and by SVM, retrospectively. The volume estimation was performed in our study using a different approach that consisted of three separate stages combined with the Cavalieri method of modern design stereology. RESULTS: The response rates were -17 +/- 55% and -12 +/- 37% by the Cavalieri method and SVM, respectively; however, they were not statistically significant (P = 0.59 and 0.21 for the Cavalieri method and SVM, respectively). Although some cases had comparable results, others had different response rates, and the two methods showed no significant correlation (r = -0.31, P = 0.41). CONCLUSIONS: Because this modified method provides accurate results by reducing margin of errors, even in case of bizarre shape of AE, a correct, unbiased, and reliable management of the cases with AE via this method may be possible. Owing to lack of a correlation with SVM, it is suggested that a measurement via SVM may be wrong and its use in the evaluation of the treatment response in such cases will not be sufficient and completely true.     

Surgical treatment of hilar cholangiocarcinoma in the new era: the Asan experience

Background/purpose

Both curative resection and minimized in-hospital mortality offer the only chance of long-term survival in patients with hilar cholangiocarcinoma. The reported resectability rates for hilar cholangiocarcinoma have increased by virtue of combined major hepatectomy, but this procedure is technically demanding and still associated with a significant morbidity and mortality that must be carefully balanced against the chances of long-term survival.

Methods

Between January 2001 and December 2008, 350 patients with hilar cholangiocarcinoma underwent exploration for the purpose of potentially curative resection, of whom 302 (86.3%) were resected in the Department of Hepato-Biliary Surgery and Liver Transplantation, Asan Medical Center, University of Ulsan College of Medicine. Combined hepatectomy was carried out in 268 (88.7%) of 302 resected patients. Major hemihepatectomy and parenchyma-preserving hepatectomy were performed in 257 and 11 patients, respectively. Portal vein resection was associated in 40 (14.9%) of 268 hepatectomized patients. To control preoperative cholangitis and reduce risk of postoperative hepatic failure, biliary decompression through endoscopic and/or percutaneous transhepatic drainage and portal vein embolization were preoperatively applied in 329 (94.0%) of 350 explored patients and in 91 (54.2%) of 168 extended hepatectomized patients (154 right hemihepatectomy, 9 right trisectionectomy, 5 left trisectionectomy), respectively. Liver transplantation was not performed as primary treatment for hilar cholangiocarcinoma.

Results

There were 5 cases (1.7%) of in-hospital death after resection and 1 postoperative liver failure that was successfully treated with liver transplantation. Major complications were encountered in 23 patients (7.0%), and the overall morbidity rate was 43%. In 302 resections, 214 (70.9%) were curative resections (R0) and 88 (29.1%) were palliative resections (R1). The overall 1-, 3- and 5-year survival rates after resection, including in-hospital deaths, were 84.6, 50.7 and 47.3% in the R0 group and 69.9, 33.3 and 7.5% in the R1 group, respectively. The 5-year survival rate of extended hemihepatectomy of 36.4% was better than that of parenchyma-preserving hepatectomy at 10.5%. Two significant predictive factors adversely affecting survival after resection were lymph node metastasis and incurability of surgery (P < 0.001). Two patients with vascular involvement who underwent concomitant hepatic artery and portal vein reconstruction are alive after more than 3 years.

Conclusion

Preoperative biliary decompression and portal vein embolization enabled us to reduce in-hospital deaths associated with extended hepatectomy for hilar cholangiocarcinoma. Major hemihepatectomy offers an increased survival because of the higher possibility of curative resection than bile duct resection alone and parenchyma-preserving hepatectomy, but it still carries a certain mortality. Less extensive procedures can be conducted safely and are beneficial for aged patients in poor condition with a less advanced tumor stage if tumor-free resectional margins are obtained.     

非酒精性脂肪性肝病国内外诊疗指南的区别及治疗展望

非酒精性脂肪性肝病(NAFLD)是一种与胰岛素抵抗和遗传易感性密切相关的、肝脏脂肪过度堆积的代谢应激性肝脏损伤。据估计,目前世界上25%的人口被诊断患有NAFLD,对社会经济发展和人们的健康水平造成巨大影响。基于不同地区的生活习俗和人群基因差异,NAFLD在各国/地区的流行率不同,并且在NAFLD诊断标准和治疗方案上各国/地区诊疗指南给出的推荐也存在一定差异。该综述旨在对比国内外最新指南在NAFLD诊断与治疗方面的异同点,汇总最新诊疗手段研究进展,以期对NAFLD的临床诊疗提供借鉴。     

Barriers to the implementation of evidence in osteoporosis treatment in hip fracture

An audit at a private tertiary hospital showed low rates of assessment and treatment of osteoporosis in minimal trauma patients of hip fracture. A survey sent to all doctors involved in hip fracture care to establish medical beliefs about effective management of osteoporosis in minimal trauma hip fracture patients showed a lack of ownership for investigation and beliefs influencing treatment choices. Understanding the barriers to the translation of evidence into practice is vital to improve patient care.     

Effects of surgical versus medical treatment of long-term prognosis in angina at rest: an observational non-randomized study of 400 patients

The effect of surgical versus medical treatment on long-termprognosis in angina at rest was assessed using the Cox regressionmodel for survival analysis in 400 patients complaining of recurrentepisodes of resting chest pain associated with transient repolarizationchanges. The surgical group included 185 patients, and the medicalgroup 215. Surgically treated patients more frequently had two-and three-vessel disease, while single-vessel disease prevailedin medically treated patients (P<0·01). No differencebetween the two groups was found in mean values of left ventricularend diastolic pressure and ejection fraction. Three variableswere identified as independent predictors of prognosis in allpatients: left ventricular end-diastolic pressure (P < 0·001),age > 45 years (P < 0·05), and number of diseasedvessels (P < 0·05). Treatment modality did not resultin different long-term survival in the entire population. However,patients with three-vessel disease had a better outcome withsurgical than with medical therapy (P < 0·05). Although our conclusions must be tempered by consideration ofthe limitations of non-randomized studies, these results showthat surgical treatment may improve survival in patients withangina at rest and three-vessel disease.