Lung cancer screening: has there been any progress? Computed tomography and autofluorescence bronchoscopy

PURPOSE OF REVIEW: Advances in imaging technologies are currently being explored in the attempt to reduce lung cancer morbidity and mortality by achieving stage shift. We reviewed recent important publications on lung cancer screening. RECENT FINDINGS: Autofluorescence bronchoscopy has established its important role in the intervention of early central airway lesions. Multidetector computed tomography (CT) and CT-positron emission tomography may facilitate diagnosis of early parenchymal lung lesions. Practical implications of screening are reaching far beyond early diagnostic efforts per se as lead-time, length-time, overdiagnosis biases combined with low specificity of screening tests undermine its cost-effectiveness in the era of healthcare budget constraints. SUMMARY: Advanced imaging technologies may allow early detection and prudent intervention in some individuals that harbour asymptomatic early lung cancer, but disproportional expenses may be required to sieve out many more individuals at risk to attain stage shift. Confounding co-morbidities and practical hurdles may reduce screening's efficacy as it is plausible that for the majority of smokers, lung cancer may not be the ultimate cause of suffering since 90% of them will not develop lung cancer. This fact remains true despite increased use of noninvasive and minimally invasive technologies for the maximum preservation of quality of life irrespective of whether early intervention is a success or failure.     

Has there been progress in the treatment of older patients with acute myeloid leukemia?

The treatment of older patients with acute myeloid leukemia (AML) has become increasingly important as the population ages. Progress, measured by overall survival rates, has improved in younger patients, perhaps due to the use of intensive post-remission therapies, but it is unclear what will enable progress for older AML patients. The older AML patient population is very heterogeneous, and both patient-specific and leukemia-specific factors must be taken into consideration when choosing the therapy that will most benefit each patient. In addition to standard and intensive chemotherapy regimens, a number of alternative therapies for previously untreated older AML patients are currently being investigated. These include gemtuzumab ozogamicin, azacitidine, decitabine, and clofarabine.     

Is there any progress in the treatment of non-alcoholic fatty liver disease?

Despite the fact that non-alcoholic fatty liver disease(NAFLD) and its severe clinical form,non-alcoholic steatohepatitis,are becoming increasingly prevalent in the industrialised countries,there are no licensed pharmacological treatments for them.Weight loss and life modifications,antioxidant therapies and insulin-sensitising agents are the current treatment strategies and have all been tested with inconclusive results.Low sample numbers,inadequate treatment duration and invalid surrogate markers for treatment response might all account for these results.As NAFLD is a systemic rather than a liver disease,future trials should address the patient as a whole and also address cardiovascular risk factors.     

New interleukins: are there any more?

PURPOSE OF REVIEW: It is now well established that cytokines play a critical role in the regulation of the immune system. Processes such as lymphoid development, differentiation, homeostasis, tolerance and memory are all regulated by cytokines that bind the type I family of cytokine receptors. Like the interferons, which bind receptors designated as the type II cytokine receptor family, type I cytokines also have essential functions in host defence. RECENT FINDINGS: Recently, a number of new interleukins and their receptors have been discovered and their role in mounting an appropriate immune response is currently being studied. In this review we will describe the new interleukin-12 family of cytokines, which now includes two other members: interleukins 23 and 27. We will also review the newly discovered interleukins 28 and 29, also known as interferon-lambdas, which bind to the type II family of cytokine receptors, their structure and the structure of their receptors, their biological activities and modes of signalling. SUMMARY: These new molecules will certainly be the focus of active research in the immediate future. Their discovery opens the door to new therapeutic approaches to the treatment of various diseases ranging from infections from intracellular pathogens to viral infections.     

Assessment of outcome in dyspepsia: has progress been made?

There is a lack of consensus among researchers on how to best measure outcome in functional dyspepsia trials and more importantly a lack of validated outcome measures. If symptoms resolve completely, treatment has been successful but with partial improvement interpretation is less straightforward. It is most likely that these issues will only be resolved if unequivocally efficacious treatments emerge to which the different outcome measures can be compared. Recently, a few validated outcome measures have been developed which look promising.     

Has angiogenesis been invited to the PPARty?

P. M. Barger. Has Angiogenesis Been Invited to the PPARty? Journal of Molecular and Cellular Cardiology (2002) 34, 713-716.     

Fertility of tomorrow: Are there any restrictions left?

As the concepts of society, parenthood and family evolve, the French law on bioethics has recently been updated by authorizing oocyte and sperm cryopreservation for all individuals who wish to do so, in the absence of medical indications. For women, aging irremediably impairs reproductive competence, both quantitatively and qualitatively. For men, aging has a negative impact on sperm parameters. Hence, this possibility of social oocyte/sperm freezing is a real breakthrough, offering to all the opportunity to better anticipate age-related fertility decline and be better actors of one's reproductive life. In its current form, the new French bioethics law allows unrestricted access to fertility preservation techniques to all women and men that fulfill the age criteria. In light of the lack of official recommendations, many questions remain. In clinical practice, it is therefore up to centers to determine on a case-by-case basis the limits of these procedures, notably to define when to stop fertility preservation. This also questions the place of the patient as a decision maker in the procedure and to which extent these procedures should be performed according to patient preference. Altogether, despite the wide range of possibilities enabled by these major legal and technical advances, it is essential to make clear to all that undergoing fertility preservation procedures is not a guarantee of future pregnancy and does not replace timely care of fertility issues.     

Evidence-based medicine in HBP surgery: Is there any?

BACKGROUND: Evidence-based medicine (EBM) has become widely accepted as a basis for clinical decision in many fields of medicine. This review examines the specific role of EBM in hepato-biliary and pancreatic (HBP) surgery. EBM relies on four main sources, including clinical guidelines, meta-analyses, primary information and clinical experience. Randomized controlled trials (RCTs) constitute the cornerstone of EBM and a recent study reported that there are relatively few RCTs evaluating the effectiveness of surgical therapies and procedures (1,530 out of 45,342 or 3.4% in five leading surgical journals) and only a few in HBP surgery. Although the effort must be to implement EBM as far as possible in HBP surgery, there are several obstacles to conducting RCTs in HBP surgery, including problems associated with standardization of surgical skills, sham-operations often impossible to perform, and the general applicability of specific findings may be uncertain. DISCUSSION: This paper will provide two relevant examples of EBM in HBP surgery in patients with hepatic metastases and pancreatic adenocarcinoma, illustrating some problems but also the potential of introducing EBM in HBP surgery. In the future, our effort must be devoted to implementing EBM in applicable areas of HBP surgery but also remembering that in certain areas accumulated knowledge from observational studies, including drainage of abscesses and surgical treatment of intestinal obstruction, may have similar or even higher clinical value than RCTs.     

Has the problem of heart failure been solved?

Emphasis on the management of heart failure has shifted from attempts to alter hemodynamics and symptoms to attempts to interfere with the natural history of the disease. This shift in emphasis has been stimulated by the recognition that heart failure progresses despite therapy and that shortened life expectancy makes the disease as lethal as most cancers. Most recent trials have therefore focused on mortality and have evaluated therapies designed to impact on progression of the syndrome. In this article the results of several recent trials are discussed, as well as the future of effective therapy.     

Stapled versus Ferguson hemorrhoidectomy: is there any evidence-based information?

AIMS: The objective of this study was to compare the perioperative, short-term, and long-term outcomes of stapled hemorrhoidectomy with Ferguson hemorrhoidectomy. MATERIALS AND METHODS: The present meta-analysis pooled the effects of outcomes of a total 926 patients treated with stapled or Ferguson hemorrhoidectomy in five out of 122 screened for retrieval randomized controlled trials using the fixed-effects or a random-effects model. RESULTS: Stapled hemorroidectomy was equivalent to the Ferguson procedure in comparisons pertaining to the following outcomes: hospital stay, postoperative hemorrhage requiring intervention, early postoperative bleeding <4 weeks, late postoperative bleeding <8 weeks, and the presence of anal pathology at 1 year follow-up. Stapled hemorrhoidectomy was superior with impact to operative time, pain visual analogue scale score at 24 h, urinary retention, and wound healing. CONCLUSIONS: There is convincingly apparent evidence about the safety and efficacy of stapled hemorrhoidectomy in the comparison with the well-established Ferguson procedure.     

Open versus closed day-case haemorrhoidectomy: is there any difference?

Background and aims Nowadays there is still controversy as to whether open or closed haemorrhoidectomy is the surgical treatment of choice for haemorrhoidal pathology.Patients and methods We carried out a randomised prospective study in the Day Surgery Unit comparing 100 patients undergoing Milligan-Morgan haemorrhoidectomy (group A) versus 100 patients undergoing Ferguson haemorrhoidectomy (group B) for symptomatic haemorrhoids, in whom medical treatment or rubber band ligation had failed.Results Characteristics of the population were: mean age 43.5 years, with predominance of males, 123 vs. 77; 88% ASA I-II. Clinical presentation: 95% rectal bleeding; 87.5% third-fourth degree. The anaesthetic technique of choice was local anaesthesia plus sedation in 180 patients (90%). Length of surgery: 24 min (group A) and 30 min (group B) (p=n.s.). Resection of three haemorrhoidal cushions was done in 87.5% of cases. There were no re-operations or re-admissions after discharge. Symptomatic recurrence, stenosis and incontinence were not found during the follow-up of the first year. Postoperative pain during the first postoperative week was greater in the open haemorrhoidectomy group, but the difference was statistically significant (p<0.05) only during bowel movements. There was complete healing in 40% of the patients in group A and 90% of those in group B (p<0.05) after 1 month. After 1 year, the results and complications were similar in both groups (p=n.s.).Conclusions Closed haemorrhoidectomy gives better results in terms of pain and healing than open haemorrhoidectomy, whereas recurrence and complications are similar after 1 year.     

Baked milk tolerant patient: Is there any special feature?

BackgroundDetermining whether patients with cow's milk allergy (CMA) can tolerate foods produced with baked milk could provide a better quality of life, a better prognosis, and an option for desensitization.ObjectivesThe aim of this study was to identify which patients over four years of age with persistent CMA could tolerate baked milk, to compare the clinical and laboratory characteristics of reactive and non-reactive groups and to describe their clinical evolution.Materials and methodsA cross-sectional study was conducted (January/13 to November/14) that included all the patients followed at a food allergy center who met the inclusion criteria. The patients underwent an oral food challenge (OFC) with a muffin (2.8 g of cow's milk protein). To exclude cow's milk (CM) tolerance, the patients were subsequently challenged with unheated CM.ResultsThirty patients met all the inclusion criteria. Fourteen patients (46.7%) were considered non-reactive to baked milk and reactive to unheated CM. When the groups that were reactive and non-reactive to baked milk were compared, no statistically significant differences in clinical features were found. The prick test for α-lactalbumin (p = 0.01) and casein (p = 0.004) and the serum specific IgE for casein (p = 0.05) presented statistical differences. After one year, none of the patients who were reactive to baked milk were ingesting CM, while 28% of the tolerant patients were consuming fresh CM (p = 0.037).ConclusionsBaked milk can be tolerated by patients with CMA, especially those with lower levels of casein and α-lactalbumin. This option can improve quality of life and accelerate tolerance.     

Medical treatment of uncomplicated diverticular disease of the colon: any progress?

Clinical evidence supports a therapeutic approach to uncomplicated, symptomatic diverticular disease of the colon by means of increased fiber intake and cyclic administration of the non absorbable antibiotic agent rifaximin polymorph-alpha. Alternate treatments such as mesalazine and probiotics have been recently proposed but no definitive conclusions on their efficacy can be drawn until larger, randomized placebo-controlled studies will be available.