Is primary angioplasty for some as good as primary angioplasty for all?

OBJECTIVES: To investigate whether proper patient selection might allow most of the benefits of population-wide primary coronary angioplasty to be captured in a subgroup of high-risk patients. BACKGROUND: Despite growing evidence that angioplasty yields better outcomes, thrombolytic therapy remains the most common form of reperfusion therapy in acute myocardial infarction (AMI) because of limited capacity for primary coronary angioplasty at most hospitals. METHODS: We used a validated logistic regression model, based on individual patient characteristics, to estimate the distribution of mortality risk in a community-based sample of 1,058 patients who received reperfusion therapy for AMI. To estimate the benefits across different baseline risks, we examined the results of 10 randomized controlled trials using meta-regression techniques. RESULTS: Assuming a constant relative risk reduction, 68% of all mortality benefits in our community-based patient sample could be captured by treating only those patients in the highest quartile of mortality risk and 87% of the benefit could be captured by treating those in the highest half. Moreover, meta-regression of the results from the 10 clinical trials suggests that patients with a mortality risk of less than 2% may be unlikely to receive any mortality benefit. With this risk-benefit relationship, treatment of only the 39% of patients with the highest risk would yield equivalent mortality outcomes to population-wide angioplasty. CONCLUSION: Most of the incremental benefits of primary angioplasty can be achieved by treating high-risk patients. For these patients, thrombolytic therapy may be difficult to justify if nearby primary angioplasty is available. For most patients, however, thrombolytic therapy appears to be an effective alternative.     

Hartmann's procedure or primary anastomosis?

Perforation following acute diverticulitis is a typical scenario during the first attack. Different classification systems exist to classify acute perforated diverticulitis. While the Hinchey classification, which is based on intraoperative findings, is internationally best known, the German Hansen-Stock classification which is based on CT scan is widely accepted within Germany. When surgery is necessary, sigmoid colectomy is the standard of care. An important question is whether patients should receive primary anastomosis or a Hartmann procedure subsequently. A priori there are several arguments for both procedures. Hartmann's operation is extremely safe and, therefore, represents the best option in severely ill patients and/or extensive peritonitis. However, this operation carries a high risk of stoma nonreversal, or, when reversal is attempted, a high risk in terms of morbidity and mortality. In contrast, primary anastomosis with or without loop ileostoma is a slightly more lengthy procedure as normally the splenic flexure needs to be mobilized and construction of the anastomosis may consume more time than the Hartmann operation. The big advantage of primary anastomosis, however, is that there is no need for the potentially risky stoma reversal operation. The most interesting question is when to do the Hartmann operation or primary anastomosis. Several comparative case series were published showing that primary anastomosis is feasible in many patients. However, no randomized trial is available to date. It is of note, that all non-randomized case series are biased, i.e. that patients in better condition received anastomosis and those with severe peritonitis underwent Hartmann's operation. This bias is undoubtedly likely to be present, even if not obvious, in the published papers! Our own data suggest that this decision should not be based on the extent of peritonitis but rather on patient condition and comorbidity. In conclusion, sigmoid colectomy and primary anastomosis is feasible and safe in many patients who need surgery for perforated diverticulitis, particularly when combined with loop ileostomy. Based on our own published analysis, however, we recommend performing Hartmann's operation in severely ill patients who carry substantial comorbidity, while the extent of peritonitis appears not to be of predominant importance.     

How asymptomatic is asymptomatic primary hyperparathyroidism?

We observed several cases of patients who believed they were free of symptoms or signs of primary hyperparathyroidism (pHPT) preoperatively. reported a change of complaints following parathyroidectomy (PTX). We, therefore, decided to examine a larger group of patients to discover if these findings were incidental or of more general significance. The role of PTX in these patients with asymptomatic pHPT remains controversial. In 1991 criteria were defined at a NIH-consensus conference, according to which patients qualify for either operative therapy or long term medical surveillance. Until now, it was generally believed that the majority of asymptomatic patients would never develop symptoms. In a epidemiological cohort-study, the perioperative data of 582 consecutive patients with pHPT, including 116 asymptomatic patients (20.9%), who underwent parathyroidectomy between 1987 and 1998 were evaluated by uni- and multivariate analysis. At a median of 72 months postoperatively, all patients underwent a planned follow-up which included a standardised, validated questionnaire, physical examination and laboratory investigations. Eighty-six patients who were asymptomatic preoperatively were available for follow-up. Only eight (9.3%) were definitely asymptomatic, 4.6% of the entire, representative cohort. Postoperative improvement was reported in 81.4% of the "asymptomatic" patients. Multivariate analysis did not reveal a single or a set of preoperative measurements, that would allow to predict the retrospectively definitely asymptomatic patient. PTX resulted in normocalcaemia in 98.8% of preoperatively asymptomatic patients, with an operative morbidity of 1.2% and no mortality. Many apparently asymptomatic patients with pHPT will only realise that they did in fact have preoperative symptoms in retrospect, following PTX. This study suggests that using an up-to-date definition of asymptomatic pHPT, there are only a small number of truly asymptomatic patients and that these cannot be predicted preoperatively, as their symptoms may become apparent only after PTX. "Asymptomatic" patients with pHPT may share the same objective and subjective benefits from PTX as symptomatic patients. They should be operated as soon as the diagnosis is established.     

Is primary prevention of asthma possible?

The increased prevalence of asthma over the past quarter century has become a major public health problem for the industrialized world. Asthma is a disease process which has a strong heritable component which is impacted by multiple environmental factors. Given the rapid increase in asthma prevalence, it is difficult to ascribe the change to a genetic alteration. Therefore, the focus for understanding the changing prevalence of asthma must be on environmental factors. This article reviews factors which may contribute, in whole or in part, to the development of the disease process. In questioning whether it is possible to prevent development of a disease (primary prevention), it is critical to understand these factors. The environment may even have an impact on the fetus during intrauterine life. There does appear to be a "window of opportunity" in early life where a variety of factors, including food and inhalant allergen exposure, exposure to pollutants, and infection with both viral and bacterial agents, may be important in initiating the development of asthma and allergy. Potential approaches to primary prevention of asthma and allergy must consider each of these important factors. Given that asthma is a multifactorial disease with both complex genetic and environmental components, it is unlikely that any single intervention will significantly decrease the prevalence of asthma.     

Double primary malignancy in colorectal cancer patients—MSI is the useful marker for predicting double primary tumors

Background and aims  The incidence of double primary malignancies (DPM) is known to be higher in colorectal cancer patients than the general population. And, the role of microsatellite instability (MSI) in DPM has been previously studied. We evaluated the clinical features and association between MSI and colorectal cancer patients with DPM. Materials and methods  From September 1994 to May 2004, we reviewed 2,301 colorectal cancer patients with regard to secondary primary malignancies. A subgroup analysis was performed for MSI after January 2003. Results  One hundred forty-five patients (6.3%) had a DPM identified. In DPM group, 57 patients had a synchronous DPM (39.3%), and 88 patients had a metachronous malignancy (60.7%). Male gender (p < 0.001) and colon cancer (p < 0.001) were the factors related with the development of the DPM. Most of the second malignancies occurred within 3 years after the primary operation. The common second malignancies were stomach (58 patients, 40%) and lung (21 patients, 14.5%). In the subgroup analysis, there was a higher frequency of DPM in the MSI group when compared to the microsatellite stable group (p = 0.021). Conclusions  The careful pre- and postoperative evaluation should be paid for detecting DPM as well as for detecting recurrence in colorectal cancer patients. The results of this study suggest that MSI might be a useful marker for the detection of DPM in colorectal cancer patients.     

Prevalence of primary aldosteronism: should we screen for primary aldosteronism before treating hypertensive patients with medication?

The present review examines various reports describing prevalence of primary aldosteronism (PA) among hypertensives and the screening method of PA to better understand the current concepts used for diagnosing and managing PA among clinicians as well as specialists. Here, we describe and compare the prevalence of PA in Japan, which is well known to induce various vascular complications due to hyperaldosteronemia, resulting in cerebral infarction, myocardial infarction and renal failure, with that in another Asian area, US, European countries, Australia and Africa. The incidence rates for PA among hypertensives were recently reported to be widely raged between 3.2% and 20%. Those discrepancies are due in part to the completely different characteristics of the starting subjects used for studying the prevalence. Moreover, the criteria for screening PA among hypertensives, including aldosterone-renin ratio (ARR), and confirmatory tests for definitely diagnosing PA, such as saline infusion test are varied. We had already reported that a diagnosis of PA was made in 61 (6%) of the 1,020 hypertensive patients during the past five years, from 1995 until 1999. In our study, only 18% of the patients showed a serum K level of 3.3 mEq/l or less. Thus, many clinicians seem to misdiagnose PA as essential hypertension, because of absence of hypokalemia. Finally, we describe highlight key evidence for optimal methods for screening and definitely diagnosing PA among hypertensive patients in order to avoid misjudgment before or after treating hypertensive patients.     

Has primary gastric lymphoma become more common?

Primary gastric lymphoma comprised 20% of 119 patients with gastric malignancy seen at our hospital between 1975 and 1980, even when strict criteria were applied to exclude systemic lymphoma patients with gastric involvement. Of the 24 patients with gastric lymphoma, 16 had disease confined to the stomach and contiguous nodes. Eight with massive stomach involvement, but also evidence of distant disease were classified as "probable" primary gastric lymphoma. Symptoms, physical findings, and laboratory studies in the lymphoma patients were similar to those of carcinoma patients. Radiography was more likely to suggest benign conditions in cases with lymphoma. While endoscopy suggested malignant disease in over 80% of lymphoma patients, histologic diagnosis of lymphoma was made first by endoscopy in only 38%. Our data suggest that lymphomas are more common among gastric neoplasms than reported in the past. This cannot be accounted for by referral patterns or by improvement in diagnostic techniques. Although lymphomas appear to be more common, this is not necessarily due to a rise in their incidence. The proportionate increase in lymphomas may be due to the decline in gastric carcinoma or to a true increase in incidence.     

A case of primary Sjögren’s syndrome complicated by Graves’ disease and primary biliary cirrhosis

Abstract

A patient with primary Sjögren’s syndrome (SS) who developed Graves’ disease and primary biliary cirrhosis (PBC) is described. Co-existence of these three organ-specific autoimmune diseases has been identified based on the findings of clinical and pathological examination. Although the association of SS with Hashimoto’s thyroiditis or PBC has been well recognized, the association of SS with Graves’ disease is quite rare. Therefore, this may be the first report describing the coexistence of these three organ-specific autoimmune diseases in the same patient.