End of the road for the diet-heart theory?

A personal account of the diet-cholesterol-heart hypothesis during the last sixty years, from its start with Jeremiah Stamler and Ancel Keys, its rapid rise and progressive fall during the last years. It is pointed out that the clinical picture of a heart attack is not synonymous with atherosclerotic changes in the coronary arteries. Special emphasis is given to the repeat publication of the results with the MRFIT screenees that have been used to obscure the negative results of the randomized multifactorial trials MRFIT in the US and The Gothenburg preventive trial in Sweden. A part addresses the treatment or prevention of CHD with medicines, where the mode of action and side-effects of the statin group of medicines have been more or less been neglected in the large amount of clinical trials. A better analysis of these features of the family of statins has to be done in order to limit their use to patients who really need them.     

How well do neurosurgeons care for trauma patients? A survey of the membership of the American Association for the Surgery of Trauma

OBJECTIVE: To quantify the trauma community's perceptions about neurosurgeons' involvement in trauma. METHODS: Mail survey of the membership of the American Association for the Surgery of Trauma. RESULTS: The response rate was 33.6% (280 of 833 mailings). Eighty-four percent of respondents practiced in an academic setting, and 51% reported that neurosurgery residents were available in their hospitals at night and on weekends. Approximately 60% reported that neurosurgeons were in charge of the care of adults with isolated head injuries (HIs) who had been operated on. A similar percentage thought that neurosurgeons should be in charge of such patients' care. Only 31.5% indicated that neurosurgeons were in charge if no operation had been performed (P < 0.001 versus patients who had been operated on), but 42.1% thought that neurosurgeons should be in charge of patients who had not been operated on (P < 0.001 versus neurosurgeons who actually were in charge of such patients). The same question was asked with regard to adults with both HIs and systemic injuries and with regard to children with HIs with and without systemic injuries. In general, the actuality of a leadership role for neurosurgeons depended on whether a craniotomy had been performed, and it was believed that more neurosurgeons should be in charge than actually were in charge of patients with HIs. Reluctance to insert intracranial pressure monitors was the most commonly reported problem (44.8% of respondents) with regard to neurosurgeons' care of patients with HIs. All problems were reported to be significantly more common when in-house neurosurgery residents were not available. More than 40% of respondents indicated that non-neurosurgeons should be allowed to insert intracranial pressure monitors, and 14% thought that non-neurosurgeons should be allowed to perform trauma craniotomies. These opinions were strongly associated with the reporting of problems in neurosurgeons' performance in these areas (P < 0.001 and P = 0.001, respectively). CONCLUSION: Neurosurgeons frequently yield responsibility for managing patients with HIs to other specialists, but more frequent leadership of neurosurgeons in this area would be welcome. Reported problems with neurosurgical care of trauma patients may be related to a lack of immediate availability of neurosurgeons, such as the absence of in-house neurosurgery residents at night. Failure of neurosurgeons to address perceived deficiencies in their care of trauma patients may lead to serious erosion of the central role of neurosurgeons in managing patients with HIs.     

What is the evidence for the efficacy of cryoplasty?

Cryoplasty is a technique for treating vascular stenosis which combines balloon angioplasty with cold injury. The combination is proposed to reduce the incidence of restenosis by inhibition of neointimal hyperplasia. There have been several clinical studies which purport to show improved patency compared to conventional angioplasty. Unfortunately, these are not comparative or controlled studies and have not been performed, analyzed or reported in accordance with recognized reporting standards for peripheral vascular intervention. The studies on femoropopliteal disease have selected favourable patients. Of greatest concern is the use of surrogate endpoints in lieu of objective demonstration of vessel patency. Critical interpretation of the results fails to demonstrate any convincing superiority of cryoplasty compared to conventional balloon angioplasty. Where little difference in outcome exists between two techniques, a trial comparing them will require hundreds of patients to be sufficiently powered to demonstrate a benefit of one technique over the other. As cryoplasty is significantly more expensive than conventional angioplasty, the cost benefit ratio is unfavourable and such a trial is unlikely to occur.This article is a critical review of the technique of cryoplasty. The reader will be able to: describe expected outcomes from balloon angioplasty; describe the theoretical role for cold injury as a component of angioplasty; recognize the need to adhere to well defined standards when reporting the results of new techniques for treating vascular disease; critically review the results of cryoplasty; understand the limitations and relevance of the published clinical results of cryoplasty.     

State of the art: surgery for endemic goiter—a plea for individualizing the extent of resection instead of heading for routine total thyroidectomy

Background  

During the past 150 years of nodular goiter surgery, the pendulum has been swinging from limited to more extensive forms of thyroidectomy and all the way back reflecting the challenges of striking a balance between surgical morbidity and disease recurrence.     

Safety of long-acting β agonists for the treatment of asthma: clearing the air

Concerns about the safety of long-acting β2-agonist (LABA) therapy, has led to the appearance of multiple publications and recommendations. This review critically examines the available clinical evidence and safety requirements for LABA use. On the basis of nearly 20 systematic reviews and databases, the authors conclude that LABA monotherapy significantly increases the risk of asthma-related adverse effects. We also conclude that the use of LABAs concomitantly with inhaled corticosteroids (ICS) significantly reduces asthma hospitalisations and is not associated with life-threatening events and asthma-related deaths, especially when concurrent use of LABAs and ICS can be reasonably assured (use of a single inhaler device). An appropriate clinical study would require an extremely large sample, making it impractical. Finally, some of the new US Food and Drug Administration (FDA) recommendations have caused confusion and do not appear to be fully evidence based. Although limited by low statistical power, the evidence supports the use of LABAs plus ICS in a single inhaler device (to increase adherence and reduce the potential use of LABA monotherapy) for all patients (not only children) with moderate to severe asthma.     

Is this the end of the line for the moderate dyskaryotic smear?

OBJECTIVE: The British Society for Clinical Cytology has recently proposed that the terminology for cervical smear reporting is to be changed from a 3-tier system (mild, moderate, severe dyskaryosis) to a 2-tier system of low-grade and high-grade dyskaryosis. This modification eliminates the central category of moderate dyskaryosis which would be incorporated into the high-grade group. The aim of this study was to investigate the role of the moderate dyskaryotic smear in clinical practice. MATERIALS AND METHODS: A retrospective review of all women who were referred for colposcopy because of a moderate dyskaryotic smear was carried out for a 6-month period. Data collected included colposcopic impression, procedure performed and final histopathology. Two cytologists who were unaware of the original smear report were asked to reclassify these smears using the new 2-tier system. Their findings were compared with the documented colposcopic and histopathology results. RESULTS: One hundred women with moderate dyskaryotic smears were referred for colposcopy during the study period. Most of these were reclassified as high-grade dyskaryosis using the new system. Fifty-six (72%) of the moderate dyskaryotic smears which were correctly regraded as high grade by cytologist 1 were found to have cervical intraepithelial neoplasia 2/3 on final histopathology, whereas for cytologist 2, 66 (68%) were found to have high-grade cervical intraepithelial neoplasia. CONCLUSION: There is no clinical benefit in retaining the term moderate dyskaryosis. This study emphasizes the need for a uniform 2-tier system.     

What is the evidence for the management of urethral amyloidosis? A systematic review of the literature

What's known on the subject? and What does the study add? Urethral amyloidosis is rare and urethrotomy has been proposed as a suitable treatment option. By reviewing the literature and comparing our own experiences, we have shown urethroplasty to have good medium term outcomes in patients with urethral amyloidosis, whereas urethrotomy may lead to recurrence.

OBJECTIVE

• ? Urethral amyloidosis (UA) is a rare condition which may be encountered by an urological surgeon. We reviewed the literature regarding the presentation, investigation and management of UA.

PATIENTS AND METHODS

• ? A systematic review of the English literature on PubMed was conducted and we indentified 39 articles which reported 45 patients. We included our experience with four patients from our tertiary centre.

RESULTS

• ? The majority of patients reported symptoms consistent with a urethral structure. Most patients were treated with urethrotomy, only two patients have been reported to have had a urethroplasty in the literature. Medium and long term outcome data is lacking for urethrotomy and urethroplasty. We found recurrence in our patients after urethromoty and incomplete resection of UA. We describe short (6 month) and medium term (18 month) outcomes in two patients who underwent augmentation urethroplasty.

CONCLUSION

• ? Although urethrotomy and dilatation have been proposed in the past, we found these may still lead to disease progression and therefore urethroplasty may be the most appropriate long term management option.

     

Results of the Max Page muscle sliding operation for the treatment of Volkmann’s ischemic contracture of the forearm

Background

Volkmann’s ischemic contracture is a less common but crippling condition affecting the extremities. Once the condition sets in, the prognosis always remains guarded, even after long and intensive physiotherapy and various restorative surgical techniques. This study was undertaken to evaluate the long-term functional results of the Max Page muscle slide operation in patients with Volkmann’s ischemic contracture of the forearm of moderate degree (Tsuge classification).

Materials and methods

Nineteen patients treated between 1997 and 2009 were evaluated. The functional outcome (measured as the dexterity score, hand grip strength, sensibility, and appearance) was analyzed postoperatively. The pre- and postoperative values were compared using a paired t test. The final results were graded as good, fair, and poor.

Results

The average age at the time of presentation was 18 years (range 3–25 years). Tight external splintage for injuries around elbow and forearm was the primary factor. The mean period of follow-up was 3.53 years. Fifteen patients were able to achieve good functional results. Three had fair and one had poor results. All three variables showed significant improvements postoperatively. Wound dehiscence was the most common complication. One patient needed a second surgery to restore good hand function.

Conclusion

The Max Page muscle sliding operation to treat Volkmann’s ischemic contracture of moderate degree gives good functional results. The procedure is simple and easy to perform. Adequate muscle release and proper postoperative physiotherapy are key to achieving good results.