What is important in treating osteoarthritis? Whom should we treat and how should we treat them?

Most of the treatments used today for OA have a relatively weak evidence base to support their use, and their effect size is small. Many key questions about OA management remain unanswered, in part because of the strong bias toward research on single pharmaceutical agents rather than nonpharmacologic interventions and a comprehensive package of care involving pharmacologic and nonpharmacologic measures. Good management of OA involves the coordination of several different types of interventions provided by health care professionals; however, while a great deal of research is available on the use of individual treatments, there is a lack of information on how health services for patients who have OA should be organized. The problem is compounded by the fact that many people who have OA use complementary therapy as well as, or instead of, allopathic treatments despite the fact that most of the evidence suggests that many such interventions are no better than placebo [123], which might be because of the relatively small effects of most conventional nonsurgical treatment for OA and to the need for a more holistic, individualized approach to treatment than most conventional health professionals usually provide. For many people who have OA, the fear of side effects is a major barrier to the use of pharmacologic interventions [11]. The authors believe that future research in OA therapeutics should concentrate more on behavioral and physical interventions than on drugs, should examine packages of care involving combinations of treatment modalities, and should include a consideration of patient preferences. The authors also believe that the academic community striving to provide help for people who have OA should bear in mind the concept that there is "too much medicine" [37].     

Ongoing trials: What should we expect after ALLHAT?

The publication of the Antihypertensive and Lipid-lowering Treatment to Prevent Heart Attack Trial (ALLHAT) results, when used in conjunction with a new meta-analysis, provides hypertension research with a watershed. Data demonstrate clearly that lowering blood pressure is the most important aspect of hypertension management, and that all agents are similarly effective. There is little sustainable evidence for pressure-independent advantages for any class of drug at this time. Therefore, by combining these findings with additional information on target levels of blood pressure and safety, plus the use of aspirin and statins, we can formulate health care policies that attack hypertension in a holistic risk-based way. The future will focus on gaining extra benefit for patients by testing the efficacy and superiority of drug combinations using novel agents that favorably influence intermediate markers such as arterial stiffness, and arresting the ever-increasing burden of cognitive impairment and dementia.     

Which cost of alcohol? What should we compare it against?

This paper explores and develops issues raised by recent debates about the cost of alcohol to England and Wales. It advances two arguments. First, that the commonly used estimates for alcohol harm in England and Wales are outdated, not fully reliable and in need of revisiting. These estimates rely on data that are between 4 and 12 years out of date and sensitive to questionable assumptions and methodological judgements. Secondly, it argues that policymakers, academics and non‐governmental organizations should be more careful in their use of these numbers. In particular, it is imperative that the numbers quoted fit the argument advanced. To help guide such appropriate usage, the different types of cost of alcohol are surveyed, alongside some thoughts on the questions they help us to answer and what they imply for policy. For example, comprehensive estimates of the total social cost of alcohol provide an indication of the scale of the problem, but have limited policy relevance. External cost estimates represent a ‘lowest common denominator’ approach acceptable to most, but require additional assumptions to guide action. Narrower perspectives, such as fiscal, economic or health costs, may be relevant in specific contexts. However, optimal policy should take a holistic view of all the relevant costs and benefits. Similarly, focusing solely on tangible costs may be less controversial, but will result in an under‐estimate of the relevant costs of alcohol.     

Diverticular colovesical fistula: What should we really be doing?

Background

Colovesical fistula secondary to diverticular disease is increasing in incidence. Presentation and severity may differ, but a common management strategy may be applied. The aim of this study is to evaluate the characteristics and perioperative management of patients with colovesical fistulae and determine optimal management.

Methods

From 2003 to 2012, all charts of surgical patients with diverticular colovesical fistulae at two different institutions were reviewed. Patient and presentation characteristics and perioperative management and outcomes were recorded. Patient groups with early and late catheter removal (< 8 and ≥ 8 days) were compared with significance level set at p < 0.05.

Results

Seventy-eight patient charts were reviewed. The mean duration of symptoms was 7.5 months. Laparoscopic assisted surgery was carried out in 35% of patients. Complex bladder repair was performed in 27%. Mean length of stay was 8 days. Mean urinary catheter duration was 13 days. Seventy percent of patients underwent postoperative cystogram, with 4% positive for extravasation. Patients with early catheter removal were significantly older, more likely to have received intraoperative methylene blue instillation, and less likely to have had a complex bladder repair (p < 0.05). Complication rate, length of stay, postoperative cystography, and stent use were similar for both catheter removal groups.

Conclusions

Intraoperative methylene blue bladder instillation should be utilized to limit unnecessary bladder repairs. In the setting of negative methylene blue extravasation, surgeons may confidently remove urinary catheters in 7 days or less, in some cases as early as 48 h. In complex bladder repairs, cystogram is still an important adjunct, with those patients with negative studies benefiting from catheter removal at 7 days or less.

     

What glucose target should we aim for in myocardial infarction?

Hyperglycaemia in the period following myocardial infarction is associated with increased mortality and there is some evidence that its treatment can improve survival. However, it remains unclear as to what the ideal glucose targets might be. This study examined observational data taken from a previously reported randomised controlled trial of insulin therapy for myocardial infarction (The Hyperglycaemia: Intensive Insulin Infusion In Infarction Study), to determine optimal glucose levels for this period. Capillary glucose readings were recorded at 8 standard time points for 234 subjects in first 24 h after myocardial infarction. Survival over 6 months was analysed according to whether 80% of each subject's glucose readings were below specified glucose thresholds (Achievers) or not (Non-Achievers). We found that the glucose threshold at which there was greatest separation in mortality between Achievers and Non-Achievers was at 8 mmol/L [144 mg/dL] (6 month mortality 1.6% vs. 9.1%, p = 0.05). Therefore subjects who maintained the majority of their blood glucose levels below 8 mmol/L following myocardial infarction had optimal survival outcomes. We suggest that this might be an appropriate glucose target to aim for in the peri-infarct period.     

Achalasia: should we or should we not follow the bag?

This article concerns the long-term therapeutic effect of pneumatic dilations (PDs) in achalasia. Specifically, it is a retrospective study that follows a large cohort of achalasia patients treated with PD. Efficacy and need for repeat PDs were determined utilizing a score obtained from measuring symptoms after PD. After PDs that resulted in symptomatic improvement, patients were followed at 6-month intervals to determine the need for repeat PD. The major point of this article is that exacerbations of symptoms may occur in 35% of patients undergoing PD; however, follow-up at specific intervals using a symptom score to determine the need for repeat PD resulted in excellent long-term success. This article emphasizes the need for continued follow-up of achalasia patients following initial successful therapy.     

Acute management--how should we intervene?

A crucial question in the acute management of the patient with unstable coronary artery disease (UCAD) is whether to carry out early intervention, performing angiography soon after presentation and following this with revascularization where appropriate, or whether to follow a noninvasive medical strategy as far as possible unless symptoms necessitate intervention. The body of literature addressing this question is sparse, but the recent Fast Revascularization during InStability in Coronary artery disease (FRISC II) study has provided new insights into the problem. Using a factorial design to randomize patients to invasive or noninvasive management strategies, and to short- or long-term treatment with the low-molecular-weight heparin (LMWH) dalteparin sodium (Fragmin), it was shown in FRISC II that early invasive treatment (within 7 days), when combined with optimal medical pretreatment with dalteparin sodium, aspirin, and appropriate antianginal medication, is associated with improved clinical outcomes, relative to a "watchful waiting" approach based on noninvasive therapy. Thus, an early invasive approach following aggressive medical pretreatment should be the preferred strategy for patients with UCAD who present with signs of ischemia on the electrocardiogram or raised biochemical markers of myocardial damage at admission.