What can be expected from off-pump coronary artery surgery?

Coronary artery bypass surgery with beating heart (off-pump) has become more common in the last ten years allowing seven randomized studies with at least 60 patients, comparing off-pump and on-pump coronary bypass. Anaesthesia, monitoring and haemodynamic complications are described. Randomized studies concluded to less elevation of biochemical markers of myocardial and renal injury, less hydric inflation, less cerebral microemboli, reduction of homologous blood transfusions, of hospital stay and global costs. However in low risk patients no reduction in myocardial infarction, atrial fibrillation, stroke, acute renal failure, early reoperation, surgical site infection and mortality were observed. Non-randomized studies suggest a benefit in stroke and mortality in elderly patients but the possibility of incomplete revascularization remains.     

What progress can be expected in the management of hypertension? Forecast from 1974 to 2034

THE POSITIVE IMPACT OF TREATMENT: Antihypertensive treatments have clearly demonstrated their capacity to reduce cardiovascular mortality. The limits to the reduction in risk are imputable to insufficient early management, morbidity and poor compleance insufficiency of pharmacological treatments, absence of individualised adaptation to the causal pathology and inappropriate management of other cardiovascular risk factors. TO IMPROVE MANAGEMENT: Rather than creating more cardiovascular prevention Centres which only concern specific cases and research, it is fundamental to provide physicians, nurses and other health care workers with greater competence in hypertension and the management of cardiovascular risks. Conceptual changes are also necessary, particularly in that which concerns the end of the dichotomy between normotension and hypertension, hypercholesterolemia and normocholesterolemia and its individual and populational impact. PROMOTION OF NUTRITIONAL MEANS: Nutritional means should not be forgotten applied to accompany the whole pharmacological treatment of hypertension, they can be used for individual prevention and for reduction of the incidence of high blood pressure in the general population. NEW THERAPEUTIC STRATEGIES: Other than the search for antihypertensive drugs with greater efficacy and improved tolerance, several targets should be envisaged such as optimising the blockage of the renin-angiotensin-aldosterone system, inihibiting aldo-synthase. A CONSERVATIVE ATTITUDE: Although attractive, the individualisation of treatment based on genetic analysis will not be accessible to the majority of hypertensive patients. The attitude to be considered in 2004 consists above all in improving the use of available drugs at appropriate doses and especially in combinations at fixed-doses to allow for an easier therapeutic schedule.     

Lifestyle modifications and erectile dysfunction: what can be expected?

Erectile dysfunction (ED) is a common medical disorder whose prevalence is increasing worldwide. Modifiable risk factors for ED include smoking, lack of physical activity, wrong diets, overweight or obesity, metabolic syndrome, and excessive alcohol consumption. Quite interestingly, all these metabolic conditions are strongly associated with a pro-inflammatory state that results in endothelial dysfunction by decreasing the availability of nitric oxide (NO), which is the driving force of the blood genital flow. Lifestyle and nutrition have been recognized as central factors influencing both vascular NO production, testosterone levels, and erectile function. Moreover, it has also been suggested that lifestyle habits that decrease low-grade clinical inflammation may have a role in the improvement of erectile function. In clinical trials, lifestyle modifications were effective in ameliorating ED or restoring absent ED in people with obesity or metabolic syndrome. Therefore, promotion of healthful lifestyles would yield great benefits in reducing the burden of sexual dysfunction. Efforts, in order to implement educative strategies for healthy lifestyle, should be addressed.     

Complex fractures of the humeral head: which long-term results can be expected?

BACKGROUND: Although improved techniques of internal fixation and prosthetic replacement were introduced successfully in the field of operative fracture care, treatment of complex fractures of the proximal humerus also involving the humeral head remains to be a challenge to the trauma surgeon. We therefore investigated clinical and radiological long-term results after humeral head preserving procedures. METHODS: 41 patients with a three or four part fracture of the humeral head were evaluated on average 6.6 years (min. 4.4 y; max. 9.0 y) after the trauma. The evaluation was based on the Constant- and HSS score clinically and on the Neer score radiologically. Nine patients were treated conservatively (group A), 13 patients had primarily an operative treatment (group B) and another 19 were operated upon after failure of conservative means. 24 of the patients were female and 17 male, with an average age of 52 years (min. 14.4 y; max. 71.2 y). According to Neers 's fracture classification of humeral head fractures we saw 14 type IV, 25 times a combination of type IV and V and in another 2 cases a type VI fracture. RESULTS: In group A (conservative) the Constant score showed on average 82.0 points for the injured and 95.3 points for the contralateral shoulder, the HSS score revealed 73.6 points and Neer's x-ray score 5.6 points. Group B (operated) showed also good results on average according to a Constant score of 72.1 points (fractured humerus) compared with 98.1 points of the contralateral shoulder. HSS score was 64.7 points. The radiological results reached 4.0 points. Group C (conservatively failed, secondary operation) achieved 68.2 points for the injured side and 95.8 points for the contralateral side according to Constant and 59.5 points according to HSS score. The x-ray evaluation showed 5.3 points. Fracture type did not influence the outcome in any of the groups. There was no humeral head necrosis in group A, one in group B (2.4 %) and four in group C (9.8 %). CONCLUSION: These data show that regarding to clinical and radiological long-term results also complex fractures of the humeral head should be treated by head preserving procedures.     

What can be expected from risk scores for predicting postoperative nausea and vomiting?

Several risk scores have been developed to calculate the probabilityof postoperative nausea and vomiting (PONV). However, the powerto discriminate which individual will suffer from PONV is stilllimited. Thus, we wondered how the number of predictors in ascore affects the discriminating power and how the characteristicsof a population—which is needed to measure the power ofa score—may affect the results. For ethical reasons andto be independent from centre specific populations, we developeda computer model to simulate virtual populations. Four populationswere created according to number, frequency, and odds ratioof predictors. Population I: parameters were derived from apreviously published paper to verify whether calculated andreported values are in accordance. Population II: a gynaecologicalpopulation was created to investigate the impact of the studysetting. Populations III and IV: to meet ideal assumptions amodel with up to seven predictors with an odds ratio of 2 and3 was tested, respectively. The discriminating power of a riskscore was measured by the area under a receiver operating characteristiccurve (AUC) and an increase of more than 0.025 per predictorwas considered to be clinically relevant. The AUC of populationI was similar to those reported in clinical investigations (0.72).The study setting had a considerable impact on the discriminatingpower since the AUC decreased to 0.65 in a gynaecological setting.The AUC with the ‘idealized’ populations III andIV was at best in the range of 0.7–0.8. The inclusionof more than five predictors did not lead to a clinically relevantimprovement. The currently available simplified risk scores(with four or five predictors) are useful both as a method toestimate individual risk of PONV and as a method for comparinggroups of patients for antiemetic trials. They are also superiorto single predictor models which are just using the patients’history of PONV or female gender alone. However, our analysissuggests that the power to discriminate which individual willsuffer from PONV will remain imperfect, even when more predictorsare considered. Br J Anaesth 2001; 86: 822–7     

Partial left ventriculectomy: which patients can be expected to benefit?

Background. Although some patients with end-stage heart disease will benefit from a partial left ventriculectomy, no criteria have been found for identifying this group preoperatively. Our experience with partial left ventriculectomy at two institutions—the Texas Heart Institute in Houston, TX, USA, and Dedinje Cardiovascular Institute in Belgrade, Yugoslavia—showed a higher survival rate and better postoperative myocardial function in the Yugoslavian patients.

Methods. We reviewed data from 42 patients (21 at each center) who had idiopathic cardiomyopathy, a left ventricular end-diastolic dimension of more than 70 mm, wall thickness of 1 cm or greater, and New York Heart Association class III or IV symptoms. The only significant difference in preoperative status between the two groups was duration of symptoms. Histologic specimens, blinded as to origin, were graded with regard to myocyte hypertrophy, cytoplasmic vacuolation, and fibrosis. Computer-assisted myocyte and nuclear morphometry was also performed.

Results. Immediately postoperatively, there were no significant intergroup differences in the reduction in cardiac dimension or in corrections of mitral regurgitation. During 6-month follow-up, however, the Texas Heart Institute patients had a lower cardiac index (1.8 versus 3.0 L·min⁻¹·m⁻²; p = 0.001) and left ventricular ejection fraction (24% versus 34%; p = 0.006) than the Dedinje Cardiovascular Institute patients. The Texas Heart Institute patients differed from the Dedinje Cardiovascular Institute patients in the degree of severe or moderate changes in myocyte hypertrophy (90% versus 29%; p = 0.0003) and fibrosis (71% versus 29%; p = 0.006), as well as in the measurements of median myocyte diameter (35 ± 7 μm versus 27 ± 4 μm; p = 0.0002) and median nuclear size (15 ± 4 μm versus 12 ± 2 μm; p = 0.0029).

Conclusions. In the Texas Heart Institute patients, the significant intergroup difference in clinical outcome may have been related to increased myocyte hypertrophy and fibrosis. Further studies should be performed to determine the usefulness of these criteria in selecting patients for partial left ventriculectomy.     

Laparoscopic rectal resections and fast-track surgery: what can be expected?

Background

We present the results of combining protocols of standardized laparoscopic rectal resection (LRR) and perioperative fast track care.

Methods

Patients undergoing LRRs were identified from a prospectively maintained, institutional review board-approved database. Perioperative fast track care and laparoscopic operations were performed according to a standardized system.

Results

Thirty-seven patients were included. Conversion was performed in 2 males (5%). The mean operative time was 184 minutes (range 109 to 410 minutes). The mean hospital stay was 3.0 days (range 1 to 8 days) with 90% of patients discharged less than 5 days after surgery. No anastomotic leaks or mortality occurred and the in-hospital complications rate was 8%. Readmission occurred in 3 patients (8%). No specimen had involved distal or circumferential resection margins.

Conclusions

LRRs can be performed safely and effectively for rectal pathologies. Laparoscopy in conjunction with modern perioperative care provides rapid recovery with efficient use of hospital resources.     

Chemoprevention of prostate cancer: What can be recommended to patients?

Prostate cancer is third to lung and colon cancer as the cause of cancer-related deaths in American men. It is estimated that there will have been more than 28,000 deaths and 186,000 new cases in 2008 that will impose a significant burden on national health care costs. Chemoprevention aims to reduce both incidence and mortality through the use of agents to prevent, reverse, or delay the carcinogenic process. This study provides clinicians with information on some chemoprevention agents that have been considered to reduce prostate cancer risks, including 5-α-reductase inhibitors; statins (a class of compounds used to reduce cholesterol); NSAIDs; selenium; vitamins E and D; lycopene; allium vegetables (garlic, scallions, onions, chives, and leeks); soy/isoflavones; and green tea polyphenols. The evidence to support prostate cancer risk reduction benefits for each chemoprevention agent based on a review of the literature is provided.     

What can be learned using microarrays?

Whole-genome microarrays identify large numbers of gene expression changes that appear specifically related to disease states such as antineutrophil cytoplasmic autoantibody (ANCA) and systemic lupus erythematosus. Although understanding this enormous volume of esoteric data is difficult, a few basic concepts regarding microarray studies can significantly improve the general reader's comprehension.     

What can be done about acute renal failure?

Acute renal failure (ARF) complicates the clinical course of as many as 5% of all hospitalized patients with the critically ill and injured disproportionably at risk. Considerable effort has been expended to develop techniques to prevent ARF or to facilitate its resolution. However, to date, studies have failed to demonstrate that drugs can prevent onset or deterioration of renal function in the critically ill, and some studies have even suggested harm. Recent data suggest that NAC can reduce the incidence of ARF secondary to radio-contrast agents and improved techniques for RRT and, perhaps, new drugs aimed at improving cellular repair, will improve outcome from ARF in the future.     

Clinical audit: can we improve further?

Clinical audit is an important tool for comparing one's practice against existing standards. The authors have analysed the Junior Doctor's understanding of audit by performing a survey and questionnaire from 146 trainees, SpRs and SHOs from nine hospitals. The study showed that 107 (72.8%) performed audit and among those who performed audit, 52 (48.6%) experienced difficulty in obtaining data. This study highlights the importance of support needed to encourage the junior doctors to participate in audit programmes.