Pap smears for men: a vision of the future?

Background  

Anal intraepithelial neoplasia (AIN) rarely receives as much publicity as its neighbouring orifice, the cervix. As in the cervix, intraepithelial neoplasias are precursors to cancer in the anal canal. AIN and cervical interstitial neoplasia (CIN) undergo dysplasia as a consequence of human papillomavirus (HPV) infection. Since the advent of screening with the Pap smear in CIN, cervical cancer has plummeted to a fifth of its initial incidence. Anal cancer, however, has been rising, with a predilection for human immunodeficiency virus-infected men. HPV causes a squamous epithelial dysplasia and converts healthy tissue into AINs of increasing severity until anal cancer manifests.     

Pharmacological facilitation of primary percutaneous coronary intervention for acute myocardial infarction: is the slope of the curve the shape of the future?

Bernard J. Gersh, MB, ChB, FRCP; Gregg W. Stone, MD; Harvey D. White, DSc; David R. Holmes, Jr, MD

JAMA. 2005;293:979-986.

Current options for reperfusion therapy in patients admitted to a community hospital without cardiac catheterization facilities include administration of fibrinolytic drugs followed by observation, with referral to angiography driven by symptoms and signs of ischemia; transfer to a tertiary care center for primary percutaneous coronary intervention (PCI); or a strategy of facilitated PCI in which administration of fibrinolytics and platelet glycoprotein IIb/IIIa inhibitors (alone or in combination) is followed by transfer for immediate angiography and PCI if appropriate. We systematically analyzed multiple randomized and nonrandomized trials to review the pathophysiology of reperfusion therapy in acute myocardial infarction to derive insights about the likelihood of success of a strategy of facilitated PCI compared with transfer only or fibrinolysis only. The basis for the recommendations made herein is a hypothetical curve relating the duration of symptoms before reperfusion to reduction in mortality and extent of myocardial salvage. During the first 2 to 3 hours after symptom onset, a striking benefit of reperfusion is present; within this period, time to treatment is critical. Subsequently, a mortality benefit is still present but of decreasing magnitude over time. In this situation, the priority is to open the artery, and time to treatment is less critical. Results of facilitated PCI may depend largely on timing of presentation. If presentation is late after symptom onset (ie, on the "flat" part of the curve), there will be little mortality benefit from earlier patency and patients will be subject to the bleeding risks of fibrinolytic drugs. In contrast, among patients presenting very early (60-90 minutes after symptom onset), outcomes with fibrinolytic therapy alone are excellent, and it will be difficult for any other strategy to result in a significant improvement. But in patients presenting 2 to 3 hours after onset of symptoms, a strategy of facilitated PCI may move patients from the plateau to the descending limb of the curve, with a substantial improvement in myocardial salvage and mortality. Two large ongoing trials may provide definitive answers to these issues.

     

Drug-eluting stents: is it the beginning of the end for coronary artery bypass surgery?

Myocardial revascularization therapy of coronary artery disease is one of the most important medical advances of the past 50 years. Coronary revascularization by either bypass surgery or coronary angioplasty relieves angina and may improve the prognosis in patients with coronary artery disease. Randomized comparisons reveal no difference in survival free from myocardial infarction     

Anti-vascular endothelial growth factor: the future treatment of choroidal neovascularization in pathologic myopia?

Myopia is the most common refractive disorder.High myopia affects 27％-33％ of all myopic eyes in Asia.1,2 The pathologic myopia (PM) is the most severe vision-threatening phenotype of high myopia.3 It is also the second most common cause of choroidal neovascularization (CNV) in Asia.Unlike age-related macular degeneration (AMD) which mostly effecting elders,PM causes severe vision loss in young adults,resulting in a significant impairment of their working ability.4 PM has become the second leading cause of low vision and blindness particularly among those aged at 40-49 years in some Asia countries.     

Applied anatomy of the path of retroperitoneoscopic surgery

Objective To discover the anatomical basis of retroperitoneoscopic surgery. Methods Twenty Chinese adult cadavers including 12 men and 8 women were anatomized. The relationship between nerves, vessels of the lateral abdominal wall, retroperitoneal structures and the path of retroperitoneoscopic surgery were measured. Results In male cadavers, the distance between the iliac crest and trigonum lumbale was 4.02±1.26 cm on the left, and 3.83 ± 0.90 cm on the right. The distance between the iliac crest and iliohypogastricus nerve was 0.82 ± 0.13 cm on the left and 0.84±0.08 cm on the right. The distance between the subcostal nerve and Ⅻ rib in the posterior axillary line and midaxillary line was 0.79 ±0.26 cm,1.65± 1.12 cm on the left and 0.78 ± 0.30 cm, 1.59 ± 1.07 cm on the right respectively. The distance between the ureter of inferior pole of kidney and extra-border of psoas was 2.24 ± 0.67 cm on the left and 2.19 ± 0.73 cm on the right. The distance between crossing of the ureter and iliac ve     

Medical education and patients' responsibilities: back to the future?

Medical student learning is dependent on an unwritten agreement between patients and the medical profession, in which students "practise" upon real patients in order that, when they are doctors, those same patients will benefit from the doctors' skills. Given the increasing propensity for patients to refuse to take part in such learning, there is a danger that doctors will qualify without being truly competent. As patients, we must all ask ourselves, when asked to take part in medical teaching: if this student/trainee doesn't learn now, on me and under supervision, how will the person be truly competent next time, when this is for real, and the patient might be me or my loved one? We argue that a new and more explicit agreement is needed, in which the default should be that all patients are willing to help in the education of medical students, while we ensure that all such students are already competent in simulation before first practising upon real patients.     

Right of the living dead? Consent to experimental surgery in the event of cortical death

Ravelingien et al have suggested that early human xenotransplantation trials should be carried out on patients who are in a permanent vegetative state (PVS) and who have previously granted their consent to the use of their bodies in such research in the event of their cortical death. Unfortunately, their philosophical defence of this suggestion is unsatisfactory in its current formulation, as it equivocates on the key question of the status of patients who are in a PVS. The solution proposed by them rests on the idea that it should be up to people themselves to determine when they should be treated as dead. Yet the authors clearly believe (and state) that patients who are in a PVS are in fact dead. Finally, given the public good that their proposal is intended to achieve, the moral importance they place on the consent of a person to the use of his or her body in research is ultimately only defensible in so far as this consent represents the wishes of a living person. It is thus only a gentle caricature of their position to suggest that according to their account, consent to participation in xenotransplantation research is a "right of the living dead". The equivocation by Ravelingien et al on the question of whether these people are living or dead means that they avoid confronting the implications of their argument. The solution proposed by Ravelingien et al to the problem of how we should proceed with xenotransplantation research is therefore not as neat as it first seems to be.