简介：AbstractHypertension in pregnancy is currently defined as a systolic blood pressure (BP) of 140 mmHg or more, or a diastolic BP of 90 mmHg or more. This level of BP warrants antihypertensive therapy. Treating to a target BP of 135/85 mmHg halves the risk of severe hypertension that is itself associated with adverse maternal and perinatal outcomes, similar in magnitude to preeclampsia. While based on the results of the Control of Hypertension in Pregnancy Study (CHIPS) trial, this finding is consistent with all antihypertensive trials to date. Also, in the CHIPS trial, "tight" BP control also halved the risk of progression to thrombocytopenia and elevated liver enzymes for the mother, without adverse effects for the fetus or newborn. This was true regardless of the gestational age at which BP control was instituted. While methyldopa, labetalol, and nifedipine are the most commonly-recommended oral antihypertensives, it is not clear that one antihypertensive agent has advantages over the others for treatment of non-severe hypertension in pregnancy. No antihypertensives, including renin-angiotensin-aldosterone system (RAAS) inhibitors, have been shown to be teratogenic, although there may be an increase in malformations associated with the underlying condition of chronic hypertension. Atenolol and RAAS inhibitors should not be used once pregnancy is diagnosed, based on fetotoxicity. At present, BP treatment targets used in clinic are the same as those used at home as the differences are quite variable among hypertensive women. For treatment of acute severe hypertension, the most commonly-recommended antihypertensives are oral nifedipine, IV labetalol, and IV hydralazine, although oral agents have also been shown to be effective in the majority of women; while concerns raised about IV hydralazine-induced maternal hypotension and its consequences have not been confirmed, this medication may be an inferior antihypertensive to oral nifedipine. While treatment recommendations are based on evidence, women should be engaged in decision-making, as their values may alter target BP and antihypertensive choice. Future work will clarify the optimal target BP based on home BP measurements; whether BP targets should be lowered further if the definition of hypertension is based on a lower BP; which, if any, antihypertensive medication for non-severe hypertension is better with regards to maternal and perinatal outcomes; and whether factors beyond BP level (such as variability, race, and other physiological variables) should inform antihypertensive therapy in pregnancy.

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简介：AbstractIntraamniotic infection (IAI) or chorioamnionitis is a common cause of preterm birth and may cause adverse neonatal outcomes, including neonatal pneumonia, respiratory distress, meningitis, sepsis, and death. Maternal morbidities from intraamniotic infection include dysfunctional labor requiring increased intervention, cesarean birth, postpartum uterine atony with hemorrhage, endometritis, peritonitis, sepsis, adult respiratory distress syndrome and, rarely, death. Chorioamnionitis can result from an ascending infection, iatrogenic causes or transplacental passage from maternal blood-borne infections. The clinical findings of chorioamnionitis include maternal fever (≥38 °C), maternal (>100 beats per minute) and/or fetal tachycardia (>160 beats per minute), maternal leukocytosis on complete blood count (>15 000 cells/mm3), and uterine tenderness and/or purulent and/or foul-smelling amniotic fluid. The management of chorioamnionitis mainly includes antibiotic therapy and delivery. Women with previable preterm premature rupture of membranes should be offered realistic counseling from a multidisciplinary approach. The separation of the mother and the fetus to preserve the life of the mother should prioritize delivery methods that result in a living fetus if possible, with appropriate neonatal resuscitation available.

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简介：AbstractFetal growth restriction (FGR) is the condition in which a fetus does not reach its intrinsic growth potential and in which the shortterm and long-term risks of severe complications are increased. FGR is a frequent complication of pregnancy with a complex etiology and limited management options, other than timely delivery. The most common pathophysiological mechanism is placental insufficiency, due to many underlying causes such as maternal vascular malperfusion, fetal vascular malperfusion and villitis.Identifying truly growth restricted fetuses remains challenging. To date, FGR is often defined by a cut-off of the estimated fetal weight below a certain percentile on a population-based standard. However, small fetal size as a single marker does not discriminate adequately between fetuses or newborns that are constitutionally small but healthy and fetuses or newborns that are growth restricted and thus at risk for adverse outcomes. In 2016, the consensus definition of FGR was internationally accepted to better pinpoint the FGR population.In this review we will discuss the contemporary diagnosis and management issues. Different diagnostic markers are considered, like Doppler measurements, estimated fetal growth, interval growth, fetal movements, biomarkers, and placental markers.

简介：AbstractAmbulatory blood pressure monitoring (ABPM) has become indispensable in the current management of hypertension. ABPM is particularly useful in the accurate diagnosis of hypertension. Its diagnostic thresholds had been recently established based on hard clinical outcomes. Cross-classification of patients according to office and ambulatory blood pressure identifies white-coat, masked, and sustained hypertension. ABPM is also useful in cardiovascular (CV) risk assessment. It provides information on daytime and nighttime blood pressure and circadian rhythm, particularly nighttime blood pressure dipping. Nighttime blood pressure is predictive of CV risk independent of office and daytime blood pressure. Isolated nocturnal hypertension is a special form of masked hypertension, with normal daytime but elevated nocturnal blood pressure. It also helps in the evaluation of blood pressure fluctuation and variation, such as morning blood pressure surge and reading-to-reading blood pressure variability. ABPM may derive several other indexes, such as ambulatory blood pressure index and salt sensitivity index, which may be useful in CV evaluations.

简介：AbstractSevere asthma is "asthma which requires treatment with high dose inhaled corticosteroids (ICS) plus a second controller (and/or systemic corticosteroids) to prevent it from becoming 'uncontrolled’ or which remains 'uncontrolled’ despite this therapy." The state of control was defined by symptoms, exacerbations and the degree of airflow obstruction. Therefore, for the diagnosis of severe asthma, it is important to have evidence for a diagnosis of asthma with an assessment of its severity, followed by a review of comorbidities, risk factors, triggers and an assessment of whether treatment is commensurate with severity, whether the prescribed treatments have been adhered to and whether inhaled therapy has been properly administered. Phenotyping of severe asthma has been introduced with the definition of a severe eosinophilic asthma phenotype characterized by recurrent exacerbations despite being on high dose ICS and sometimes oral corticosteroids, with a high blood eosinophil count and a raised level of nitric oxide in exhaled breath. This phenotype has been associated with a Type-2 (T2) inflammatory profile with expression of interleukin (IL)-4, IL-5, and IL-13. Molecular phenotyping has also revealed non-T2 inflammatory phenotypes such as Type-1 or Type-17 driven phenotypes. Antibody treatments targeted at the T2 targets such as anti-IL5, anti-IL5Rα, and anti-IL4Rα antibodies are now available for treating severe eosinophilic asthma, in addition to anti-immunoglobulin E antibody for severe allergic asthma. No targeted treatments are currently available for non-T2 inflammatory phenotypes. Long-term azithromycin and bronchial thermoplasty may be considered. The future lies with molecular phenotyping of the airway inflammatory process to refine asthma endotypes for precision medicine.

简介：AbstractOver the past few decades, understanding of the pathogenesis of rheumatoid arthritis (RA) has improved substantially. Insights into the cellular and molecular mechanisms involved in RA have enabled the discovery of new therapeutic targets and led to the development of biologics and targeted synthetic disease-modifying antirheumatic drugs. In parallel with the improvement in therapies, the evolution of strategies in the management of RA has also contributed considerably to better outcomes in patients. Major changes include the development of disease activity measures, formulation of the treat-to-target principles as well as increased attention to comorbidities. The presence of comorbidities such as cardiovascular diseases may increase the mortality of RA patients, affect their treatment strategies and result in worse outcomes. Therefore, prevention and management of certain high-risk comorbidities have become increasingly important in the long-term treatment of RA. In this study, we summarized new insights into the pathogenesis and management of rheumatoid arthritis and associated comorbidities, with a special focus on the 2021 update of the American College of Rheumatology (ACR) guideline for RA and key reports presented at the 2021 ACR convergence.

简介：AbstractThe contemporary embrace of endoscopic technology in the approach to the anterior skull base has altered the perioperative landscape for patients requiring pituitary surgery. Utility of a multi-disciplinary unit in management decisions facilitates the delivery of optimal care. Evolution of technology and surgical expertise in pituitary surgery mandates ongoing review of all components of the care central to these patients. The many areas of potential variability in the pre, intra and post-operative timeline of pituitary surgery are readily identifiable. Core undertakings and contemporary controversies in the peri-operative management of patients undergoing endoscopic transsphenoidal pituitary surgery are assessed against the available literature with a view to providing guidance for the best evidence-based practice.

简介：AbstractChronic pruritus is a very common clinical symptom that seriously affects people’s quality of life. Pruritus is associated not only with skin diseases but also with a variety of systemic diseases. It brings great challenges to clinical management. To standardize the management of chronic pruritus, experts of the Allergic Disease Committee of Chinese Dermatologist Association discussed many times and finally formed this guideline to provide reference and guidance for the clinical work of dermatologists and other physicians at all levels.

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简介：AbstractSepsis, which is life-threatening organ dysfunction resulting from a dysregulated host response to infection, remains a major cause for the admission of pregnant women to the intensive care unit and is one of the leading causes of maternal morbidity and mortality. The obstetric causes include uterine infection, septic abortion, and wound infection. The non-obstetric causes include pyelonephritis and pneumonia. Maternal sepsis may also be from obstetrical critical illness, such as obstetric severe hemorrhage, obstetric (amniotic fluid/pulmonary) embolism, acute fatty liver of pregnancy, and congestive heart failure, cardiopulmonary arrest, and major trauma. The most commonly reported pathogens in maternal sepsis include Escherichia coli, Streptococcus, Staphylococcus, and other gram-negative bacteria. Maternal sepsis may cause intrauterine infection, which results in (1) preterm premature rupture of membranes or preterm labor or birth, (2) cerebral white matter damage or cerebral palsy or neurodevelopmental delay, (3) stillbirth, (4) early- or late-onset sepsis, and (5) perinatal death. The "Hour-1 bundle" should be initiated within the first hour of the recognition of sepsis. The use of early, appropriate antibiotics is crucial in the management of maternal sepsis. Fetal status should be monitored. Appropriate and early source control should be provided. The decision for delivery is often quite complex and should be individualized to each patient’s clinical scenario while taking into consideration the suspected source of infection, maternal status, fetal well-being, and gestational age. Extracorporeal membrane oxygenation has been increasingly used in refractory sepsis during pregnancy and the puerperium.

简介：AbstractTonsillectomy is a very common procedure in children, often performed on an outpatient basis. Severe postoperative pain is common, and can be prolonged. Despite a large number of available analgesic medications, often employed in combination, achieving adequate pain control remains a persistent challenge. Research suggests a tendency among caregivers to undertreat pain, and a need for detailed care instructions and education to ensure adequate pain management. Furthermore, ongoing questions regarding the safety and efficacy of the most commonly used medications have led to wide variance in practice patterns and continuous reassessment through research that yields sometimes conflicting results. This review summarizes the current state of the literature and presents a management approach which attempts to maximize pain control while minimizing potential harm with combinations of medications and modification based on patient-specific factors.

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简介：AbstractWith the widespread adoption of advanced tourniquets, the mortality rate of limb wound hemorrhage has decreased significantly, and non-compressible torso hemorrhage has gradually occupied the leading position of potentially preventable death, both in military and civilian circumstances. With the emergence of novel hemostatic devices and materials, strategies for the management of non-compressible torso hemorrhage have changed significantly. This review summarizes the current treatment strategies and types of equipment for non-compressible torso hemorrhage and suggests future research directions, hoping to provide a comprehensive review for the medical personnel and researchers engaging in this field.

简介：AbstractIntroduction:Congenital analgesia is a rare autosomal recessive hereditary disease. The primary damage of congenital analgesia is central structure damage of comprehensive pain perception.Case presentation:A 1-year-old Han Chinese boy was admitted to hospital because of a tongue bite. He had no response to noxious stimulation of the body surface and was diagnosed with congenital analgesia. A small dose of remifentanil was intravenously injected during anesthetic induction to reduce the stress response caused by endotracheal intubation. A certain depth of anesthesia should be guaranteed during anesthetic induction and surgery to alleviate the stress response induced by endotracheal intubation and the operation.Conclusion:Opioid analgesics are not required for general anesthesia in patient with congenital insensitivity to pain. With a heat dissipation barrier in patients with congenital insensitivity to pain with anhidrosis, body temperature, end-tidal carbon dioxide and bispectral index should be monitored.

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简介：AbstractMandibular condylar fractures are among the most common facial fractures and some of the most difficult to manage. Opinions about the management of mandibular condylar fractures differ among surgeons. With the implementation of new technology, an increased understanding of fracture management, and better functional and morphological outcomes reported in the literature, open reduction and internal fixation is becoming many surgeons’ preferred choice for the treatment of condylar fractures. Because surgical treatment of such fractures is complex, certain factors must be considered to achieve satisfactory outcomes. In this article, we summarise six key points in the management of mandibular condylar fractures: virtual evaluation of condylar fracture, a suitable surgical approach, good reduction, stable internal fixation, repair of the articular disc, and restoration of the mandibular arch width. We believe that these points will help to improve the prognosis of mandibular condyle fractures.