Alcohol versus exercise for coronary protection

Both alcohol and exercise have been said to protect against coronary heart disease. The epidemiologic data suggest exercise, per se, does, but alcohol, per se, does not protect against coronary heart disease. Recent longitudinal data suggest teetotalers, especially those who have never smoked, have the lowest coronary heart disease mortality of all. Other cross-sectional and longitudinal studies that suggest light drinkers have the lowest coronary heart disease mortality may be biased because: (1) the teetotalers include some ex-drinkers who may have quit drinking because of coronary heart disease; and (2) the light drinkers include some who drink very rarely, and/or drink very small amounts, and/or have a lower risk of coronary heart disease independent of alcohol because they are more health-conscious in general. The metabolic data also suggest exercise, but not alcohol, protects against coronary heart disease. Exercise increases the level of high-density lipoprotein 2, which correlates well with coronary heart disease risk; alcohol in moderation seems to increase the level of high-density lipoprotein 3, which correlates poorly with coronary heart disease risk and may merely reflect hepatic enzyme induction. Exercise and alcohol influence blood pressure, body weight, and glucose tolerance in opposite directions; in each instance, the influence of exercise is beneficial, that of alcohol detrimental, to the prevention of coronary heart disease. There seems to be no reason to use alcohol for coronary protection.     

颈动脉狭窄的干预治疗:支架还是内膜剥脱?

颈动脉狭窄是卒中的常见原因.颈动脉血管成形和支架正成为颈动脉内膜剥脱术后治疗颈动脉狭窄的一种有效方法.两种方法孰优孰劣是近来争论的焦点,现通过比较近来对颈动脉内膜剥脱术和颈动脉血管成形和支架术对比的试验研究,认为未来几年是评价两种方法的重要时期.     

Comparison of Defined versus Recommended versus Prescribed Daily Doses for Measuring Hospital Antibiotic Consumption

Background:   

Hospital antibiotic use is usually measured by calculating the volume as the number of daily doses defined by the World Health Organization/Anatomical Therapeutic Chemical (WHO/ATC) index (DDDs) divided by a denominator indicating clinical activity, such as the number of occupied bed days. Previous studies have found discrepancies between DDDs, daily doses as recommended in practice guidelines (recommended daily doses, RDDs), and truly prescribed daily doses (PDDs). Very few studies have quantified these discrepancies.     

Midazolam versus dexmedetomidine for sedation for upper gastrointestinal endoscopy

Background: The diagnostic upper gastrointestinal endoscopy (UGI) is a safe procedure although 50% to 60% morbidity and mortality due to cardiopulmonary complications. Objective: To compare safety and efficacy of dexmedetomidine vs. midazolam in UGI. Methods: We conducted a randomized controlled, double-blind, clinical trial to compare the two drugs. Patients with an indication of UGI were randomized to receive sedation with dexmedetomidine or midazolam during the procedure. We compared age, sex, physical status (ASA), body mass index (BMI), degree of sedation (Ramsay scale), recovery time and degree of satisfaction with the procedure. Results: Forty patients with an indication of UGI were included (20 in each arm). Both groups showed a similar distribution by sex, age, BMI and ASA physical status. The level of sedation was similar starting and ending the procedure according to the Ramsay scale. The dexmedetomidine group had a shorter recovery time (7.1 vs. 15.8 min, p <0.05) and satisfaction (9.9 vs. 9.0, p <0.05). Adverse effects occurred in similar proportions in both groups Conclusions: Midazolam and dexmedetomidine are suitable for endoscopic procedures of upper digestive tract. Dexmedetomidine offers shorter recovery time and better patient′s satisfaction.     

Open versus laparoscopic resection for liver tumours

Background:

The issue under debate is whether laparoscopic liver resections for malignant tumours produce outcomes which are comparable with conventional, open liver resections.

Methods:

Literature review on liver resection and laparoscopy.

Results:

There are no randomized controlled trials (RCTs) published that provide any evidence for the benefits of laparoscopic liver resections for liver tumours. In case–control series reporting short-term outcomes, laparoscopic liver resection has been shown to have the advantage of a reduced length of hospital stay. There are as yet, however, no adequate long-term survival studies demonstrating that laparoscopic liver resection is oncologically equivalent to open resection.

Discussion:

The challenge for the near future is to test the oncological integrity of laparoscopic liver resection in controlled trials in the same way that we have learned from the RCTs carried out in laparoscopic resection for colorectal cancer. It is likely that laparoscopic liver resection will then have to compete with fast-track, open liver resection. Already, concerns have been raised regarding the learning curve required to master the techniques of laparoscopic liver resection.     

Transhiatal versus transthoracic esophagectomy for esophageal cancer

Esophageal cancer continues to represent a formidable challenge for both patients and clinicians. Relative 5-year survival rates for patients have improved over the past three decades, probably linked to a combination of improved surgical outcomes, progress in systemic chemotherapy and radiotherapy, and the increasing acceptance of multimodality treatment. Surgical treatment remains a fundamental component of the treatment of localized esophageal adenocarcinoma. Multiple approaches have been described for esophagectomy, which can be thematically grouped under two major categories: either transthoracic or transhiatal. The main controversy rests on whether a more extended resection through thoracotomy provides superior oncological outcomes as opposed to resection with relatively limited morbidity and mortality through a transhiatal approach. After numerous trials have addressed these issues, neither approach has consistently proven to be superior to the other one, and both can provide excellent short-term results in the hands of experienced surgeons. Moreover, the available literature suggests that experience of the surgeonand hospital in the surgical management of esophageal cancer is an important factor for operative morbidity and mortality rates, which could supersede the type of approach selected. Oncological outcomes appear to be similar after both procedures.     

Lithotripsy versus cholecystectomy for management of gallstones

Extracorporeal shock-wave lithotripsy is a new treatment method that effectively disintegrates radiolucent gallstones and is associated with a low complication rate. Using the model of a Markov process for decision analysis, survival and costs under four possible strategies to treat gallstones were compared: expectant management with cholecystectomy (EC) or lithotripsy (EL) reserved for symptomatic gallstones; prophylactic cholecystectomy (PC) or lithotripsy (PL) for all gallstones. Life expectancy for the different strategies varies by few days. Only if high annual rates of pain and complication occurred in subjects with silent gallstones would both prophylactic procedures marginally increase life expectancy. Prophylactic cholecystectomy then would be more cost-effective than prophylactic lithotripsy. Expectant strategies remain much cheaper than prophylactic management over a broad range of probability values and procedural costs. Expectant use of lithotripsy costs less than cholecystectomy. A low success rate of lithotripsy would raise the direct costs of lithotripsy above those of cholecystectomy but leave total costs of both strategies in the same order of magnitude. Lithotripsy appears to be a feasible alternative to treat symptomatic but not asymptomatic gallstones.     

Randomized versus historical controls for clinical trials

To compare the use of randomized controls (RCTs) and historical controls (HCTs) for clinical trials, we searched the literature for therapies studied by both methods. We found six therapies for which 50 RCTs and 56 HCTs were reported. Forty-four of 56 HCTs (79 percent) found the therapy better than the control regimen, but only 10 of 50 RCTs (20 percent) agreed. For each therapy, the treated patients in RCTs and HCTs had similar outcomes. The difference between RCTs and HCTs of the same therapy was largely due to differences in outcome for the control groups, with the HCT control patients generally doing worse than the RCT control groups. Adjustment of the outcomes of the HCTs for prognostic factors, when possible, did not appreciably change the results. The data suggest that biases in patient selection may irretrievably weight the outcome of HCTs in favor of new therapies. RCTs may miss clinically important benefits because of inadequate attention to sample size. The predictive value of each might be improved by reconsidering the use of p < 0.05 as the significance level for all types of clinical trials, and by the use of confidence intervals around estimates of treatment effects.