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PubMed2005

Diagnosis and treatment of acromegaly and its complications: consensus guidelines.

In February 1999, May 2000 and April 2002, three workshops were held in Cortina, Montecarlo and Versailles, respectively, to develop a consensus defining the diagnosis and treatment of acromegaly and its complications. The workshops were sponsored by the Pituitary Society and European Neuroendocrine Association. Invited international participants included endocrinologists, neurosurgeons and radiotherapists skilled in the management of acromegaly. This review paper summarizes the main points of the three consensus statements published following these three workshops.

Acromegaly↗
PubMed2005

Review of Cortina criteria for the diagnosis of acromegaly.

Diagnostic protocols for acromegaly have evolved over time reflecting the refinement of assays for the biochemical assessment of the GH-IGF-I axis and greater understanding of disease process. In February 1999, an International Consensus Conference was held in Cortina, Italy, to define the criteria for cure of acromegaly. This review paper summarizes the diagnostic guidelines proposed in the consensus statement by Giustina et al. In recent years, however, the criteria for both biochemical assessment and long-term monitoring in patients with acromegaly have changed with the development of increasingly sensitive and specific GH assays coupled with the widespread availability of reliable IGF-I assays. For this reason, constant updating of the assessment criteria proposed in the workshop held in Cortina, in 1999, would be advisable.

Acromegaly↗
PubMed2005

Biochemical evidence supporting the Cortina criteria.

Whether acromegaly is inactive or active, respectively cured or not cured depends on the GH suppressibility and the basal IGF-I level. According to the Cortina criteria, GH suppression after oral ingestion of 75 g glucose to <1 microg/l using conventional polyclonal immunoassays and an IGF-I level within the age-matched normal range are regarded as evidence of good control of acromegaly. According to more recent publications, mortality, which is increased in active acromegaly, is normalized when GH and IGF-I levels have become normal as defined above. Morbidity, i.e. typical features of acromegaly like cardiac problems, carpal tunnel syndrome, carbohydrate intolerance, and excessive sweating may also improve though painful arthropathy, and coarse facial features usually remain unaltered even if the biochemistry has been completely normalized. Using more sensitive GH assays, a group of acromegalic patients was shown to have normal IGF-I levels after surgery, with post-glucose levels of GH <1 microg/l but >0.14 microg/l, which is the upper level of normal subjects and of a second group of successfully operated acromegalic patients. The latter group also had slightly lower IGF-I levels, though such levels were normal in both groups. Whether this may indicate that these patients who have higher GH levels after oral glucose measured with the more sensitive immunoradiometric assay (IRMA) will more likely develop recurrences remains to be demonstrated in a larger cohort. According to the criteria put forward in Cortina d'Ampezzo in February 1999, all patients who have post-glucose GH levels <1 microg/l and normal age-matched IGF-I levels have to be regarded as well controlled, i.e. sufficiently treated. Because of lack of evidence, there is at present no reason to change the consensus reached there.

Acromegaly↗
PubMed2005

Biochemical evidence in favor of revising Cortina criteria.

There is evidence that the Cortina criteria for the cure of acromegaly are not strict enough if the aim is to predict patients where cure will be successful as opposed to patients who will suffer disease recurrence or will have mortality and morbidity return to disease-like levels. These criteria depend on biochemical measurements of GH and IGF-I that are not universally standardised or comparable, even when excluding the older, less sensitive polyclonal radio immuno assay (RIA). The biochemical evidence suggesting a revision of the criteria for curing acromegaly and derived proposals can be summarised as follows: A) Using immunoradiometric assay (IRMA) for GH measurement, no acromegalic patient with elevated IGF-I suppressed GH after 100 g oral glucose tolerance test (OGTT) to < or = 0.14 microg/l, but 50% suppressed to <1microg/l. B) With hourly GH measurements using IRMA, cured acromegalic patients exhibit basal GH values < or = 0.33 microg/l (x +/- 2 SD). C) In patients with normal IGF-I having GH after OGTT suppressed to < or = 0.14microg/l no recurrences were observed, while in 19% with GH >0.14 microg/ showed recurrences (4, 5); however, this was not the experience of others. D) Polyclonal assays for GH exhibit overlap of GH suppression after OGTT between normal subjects and active patients and should therefore be avoided. E) A recent agreement for implementing universal rhGH reference standards by September 2006 will hopefully facilitate the comparison of different assays in the future. F) Reliable IGF-I assays require age- and sex-matched reference ranges. G) For evaluation of long-term biochemical assessment after treatment, both GH and IGF-I should be undertaken. H) In order to monitor treatment with GH-receptor antagonists, a reliable IGF-I assay is of critical importance, since GH measurements cannot be used to evaluate treatment efficacy.

Acromegaly↗
PubMedDate not supplied

[Technical options in bariatric surgery and their mechanisms of action].

In recent years, bariatric surgery has enjoyed a high level of approval. There are several technical and surgical options. Most of the departments of obesity surgery perform usually the same procedure, when just in a few center the procedure can be adapted depending on the patient need. In this paper the most popular technical choices in our country are presented based on the Consensus Conference that is taking place now in the Italian Society of Obesity Surgery (SICOB), in order to give our guidelines and policies.

Bariatric Surgery↗
PubMed2005

Value of the evidence-based consensus conference.

The purpose of this paper is to describe how the inherent strengths of an evidence-based (EB) workshop can be combined with the conventional wisdom generated by a group of experts participating in a consensus conference. A traditional consensus conference is an appropriate way to arrive at the best current way to do something if the knowledge base is insufficient to make a scientifically rigorous EB analysis of the clinical problem. The result is the best opinion of experts in the field. The EB approach is the application of a repeatable review process to an existing knowledge base that is relevant to a focused question of clinical importance. It is a powerful tool that can help dentists in clinical decision-making processes. A combination of the EB approach with a consensus conference provides the highest level of evaluation and the strongest level of evidence upon which to make clinical decisions. Application of any of these sources of information can be used in the development of healthcare standards. However, standards are complicated statements that blend current scientific knowledge and clinical judgment with cultural, societal, and economic issues. When healthcare standards are being developed or revised, it is important that all sources of information be considered and the target population and purposes of the standards be identified.

Consensus↗
PubMed2006

Practical management of avian influenza in humans.

There has been much alarm about avian influenza and its potential for a global pandemic ever since the current epidemic of avian influenza infections in humans began in 2003. While there have been a number of published reports on the clinical features of avian influenza, there are few guidelines on the practical management of patients with avian influenza. A symposium organised by the Society of Infectious Disease (Singapore), Society of Intensive Care Medicine and the Singapore General Hospital was held in Singapore to gather the views of experts from Turkey, Thailand, Vietnam and Indonesia who collectively had first-hand experience of the management of the majority (more than 100 of 192) of cases of avian influenza worldwide. The experts emphasised the importance of adapting international guidelines to the practicalities of situations on the ground. There was stress on wide screening using clinical criteria primarily, molecular diagnostic techniques (with reference laboratory confirmation) for diagnosis, and rational use of antiviral prophylaxis as well as infection control using at least surgical masks, gowns and gloves. A detailed analysis of data from a pooled database from these and other affected countries is critical to building up the evidence base for practical internationally applicable guidelines.

Antiviral Agents↗
PubMed2006

[Antenatal corticotherapy: ten years after the first conference of consensus].

Beneficial effects of antenatal corticotherapy on neonates are now well established. However, after the first conference of consensus, three controversial issues were left unresolved = use of dexamethasone or betamethasone, ideal number of curses to be given, and appropriateness of corticotherapy in case of prmature of the membranes. A literature review suggests that betamethasone is preferred to dexamethasone, that prscription of a single course is more advisable than multiple courses, and that antenatal corticotherapy is finally not contraindication in case of premature rupture of membranes.

Betamethasone↗
PubMedDate not supplied

[Clinical guidelines for the management of gastrointestinal stromal tumors].

Treatment of gastrointestinal stromal tumors (GIST) has been revolutioned by the recently discovered molecular mechanism responsible for the oncogenesis of this disease. In addition, due to the rapid progress at molecular and clinical level observed in the last few years, there is a need to review the current state of the art in order to delineate appropriate guidelines for the optimal management of these tumors. A panel of experts from several specialities, including medical oncology, surgery, pathology, molecular biology and imaging, were invited to participate in a meeting to present and discuss a number of pre-selected questions, and to achieve a consensus according to the categories of the National Comprehensive Cancer Network (NCCN) and the Standard Options Recommandations (SOR) of the French Federation of Cancer Centers. Generally, consensus points were from categories 2A of the NCCN and B2 of the SOR. Conventional histologic examination with immunohistochemistry for CD117, CD34, SMA, S-100 and desmin is considered standard. Molecular analysis for the identification of KIT and PDGFRA mutation may be indicated in CD117-negative GIST. Complete tumor resection with negative margins is the optimal surgical treatment. Adjuvant imatinib should be considered an experimental approach. Neoadjuvant imatinib is also experimental, although its use may be justified in unresectable or marginally resectable GIST. Imatinib should be started in metastatic or recurrent disease, and should be continued until progressive disease or drug intolerance. In these cases, sunitinib can be used. The optimal criteria for the assessment and monitoring of GIST undergoing imatinib therapy are not well known, but they should include reduction in tumor size and disease stabilization, as well as reduction of tumor density on CT scan and metabolic activity on PET scan.

Antineoplastic Agents↗
PubMed2006

[New features in the recommendations of the Second Hungarian Therapeutic Consensus Conference].

The First Hungarian Therapeutic Consensus Conference took place on 3rd Nov. 2003 with the participation of 9 medical societies. Over the past 2 years the results of new major studies have been published and the American ATP III has also updated its guidelines issued in 2004. Based on the above proposals, the Second Hungarian Therapeutic Consensus Conference held on 3rd Nov. 2005 partly confirmed its earlier suggestions, but made some changes as well. Within the high risk category the Conference optionally created a very high risk group from those patients who - in addition to their cardiovascular disease--have either diabetes or metabolic syndrome or acut coronaria syndrome or who are chain smokers. We have included - as a complement - into the asymptomatic high risk category such newly emerging risk factors, one of which already in itself means high risk: ankle/arm index < or = 0.9, GFR <60 ml/min, microalbuminuria (30-300 mg), preclinical atherosclerosis (plaque). Besides, 4 other risk factors were also categorised such as Lp/a (> or = 30 mg/dl), CRP (> or = 3mg/l), homocysteine (> or = 12 micromol), familiarity--atherogenic gene constellation, but only the presence of at least two of these verify high risk. In very high risk group the goals of 3.5 mmol/l and 1.8 mmol/l were determined as therapeutic option. The goal in obese patients--expressed earlier only in BMI--can now be equally determined by the abdominal circumference (94 cm for men, 80 cm for women respectively). ACE inhibitors were recommended earlier as a preventive therapy in case of dysfunction of the left ventricle, while at present they are suggested for all patients with cardiovascular disease. In the recent recommendations guidelines related to nutrition, smoking, exercise have also been included.

Abdominal Fat↗
PubMed2006

[Cancer board--new medical system in cancer clinic].

To proceed with more patient-oriented cancer medicine, the development of a new medical system is necessary in Japan. In Ariake Hospital of the Japanese Foundation for Cancer Research, a new medical system has been developed, which is composed of a common outpatient clinic and a conference system. The core conference system is called "Cancer Board". The practice of patient-oriented medicine in gastroenterological cancer has been introduced as a sample of the Cancer Board system in our hospital.

Ambulatory Care Facilities↗
PubMed2006

Therapeutic goals for effective platelet inhibition: a consensus document.

Clopidogrel combined with aspirin is the mainstay of antiplatelet therapy for patients who present with acute coronary syndromes as well as following either bare metal or drug-eluting stent placement. Limitations of clopidogrel therapy include the relatively long time course required to achieve maximal inhibition of platelet aggregation, individual variability in response to its effect, the risk of bleeding during its administration, and the irreversible nature of P2Y12 receptor binding, which leads to a prolonged time course for recovery of platelet function following discontinuation of clopidogrel. Several investigational P2Y12 receptor antagonists have pharmacological properties that may overcome some or all of these limitations. These novel agents such as prasugrel, AZD6140, and cangrelor are in advanced stages of clinical development for potential use in patients with coronary artery disease.

Consensus Statements as Topic↗
PubMed2006

[Compliance with the 2002 consensus document of the Spanish Society of Nephrology for the control of diabetic nephropathy in Catalonia (ECCODIAB)].

OBJECTIVE: To evaluate the level of compliance with the 2002 consensus document (Spanish Society of Nephrology) on guidelines for the detection, prevention and treatment of diabetic nephropathy in Catalonia. SUBJECTS AND METHODS: Multicenter (23 hospitals), observational, cross-sectional, descriptive study conducted in 413 diabetic patients (61.7% men, 38.3% women) with a median age of 66.2 +/-11.5 years (26-93 years). The ANOVA test (post-hoc analysis; p value< 0.05) was used to study the relationships between the stages of diabetic nephropathyand different variables. RESULTS: 90.3% of the patients had type 2 DM. The following anthropometric parameters were observed: BMI 29.8 +/- 5 kg/m2 (BMI > 30 kg/m2: 48.7%) and waist circumference 104.1 +/- 14 cm (48.6% men > 102 cm and 78.9% women > 88 cm). Serum creatinine 1.9 +/- 1.3 mg/dl and simplified MDRD equation 45.3 +/- 25.0 ml/min/1.73 m2 [65.8%with CKD stages 3 and 4]. 80% of patients had ophthalmologic examination and 52.8% antiplatelet treatment. Hb A1c was 7.3 +/- 1.3%, but the percentage of patients with glycated hemoglobin > 7% and 8% was 54.9 and 28.6% [only 50.2% had been seen by an endocrinologist in the last 6 months]. 52.8% of patients were treated with insulin and 44.1% with anti-diabetic drugs, although only 19.6% used the new anti-diabetic drugs. 61% of patients had an LDLc > 100 mg/dl (61% treated) and 44% had triglycerides (TG) > 150 mg/dl (72% treated). 95% of patients presented with hypertension (BP > or = 130/80 mmHg),91% were undergoing antihypertensive treatment (79.7% with angiotensin-converting enzyme inhibitors and / or angiotensin receptor blockers). 81% with microalbuminuria and 78%with established proteinuria were receiving anti-proteinuric treatment. Of the patients considered to be refractory to BP (>3 drugs), only 28.9% underwent ambulatory BP monitoring. Significant differences were observed between stages of diabetic nephropathy and glycated hemoglobin (HBA1c; p = 0.048), systolic blood pressure (SBP; p = 0.024), lipidic control (HDLc; p = 0.015 and TG; p = 0.034), anemia (Hb; p = 0.010) and CKD (creatinine and sMDRD; p = 0.000). The levels of compliance with the therapeutic objectives regarding lipid control (LDL < or = 100 mg/dl and TG< or = 150 mg/dl), BP < or = 130/80 mmHg and HbA1c < or =7% were 1 objective: 68%, 2 objectives: 21.8% and 3 objectives: only 4% of patients. CONCLUSIONS: According to the results of our study, only a reduced proportion of patients fulfilled the different therapeutic end-points indicated. Future measures will be directed at improving physician-patient relationships with the main aim of intensifying the therapeutic measures to attain better metabolic and blood pressure control, nephroprotection and prevention in the appearance of cardiovascular events.

Adult↗