Are vasodilators still indicated in the treatment of severe aortic regurgitation?

Aortic regurgitation (AR) is a valve disease that causes severe complications and reduces life expectancy. Surgical correction is required in the late stages of the disease. In less advanced forms, treatment with vasodilators is a consideration. The available evidence suggests that this type of treatment has a favorable effect on the consequences of AR, particularly left ventricular remodeling. However, the impact of vasodilators on clinical endpoints complicating the course of AR remains in doubt. The limited evidence supporting or opposing the utilization of vasodilators in AR hinders drawing firm conclusions and emphasizes the process of individualized interpretation of the clinical presentation of patients with the disease.     

Does first-line surgery still have its place in the treatment of acromegaly?

Transsphenoidal surgery is currently the first-line treatment of acromegaly. Remission is observed in 80 to 90% microadenomas, 50 to 60% non-invasive macroadenomas, and less than 20% invasive macroadenomas. Predictive factors include age, maximal size of the adenoma, cavernous sinus invasion, initial hormone levels and neurosurgeon's experience. Complications are rare, with about 5% definitive diabetes insipidus and 10% of new anterior pituitary hormone deficits. Somatostatin agonist pretreatment can be proposed as it decreases tumor volume in about 25% cases and might reduce the rate of immediate postsurgical complications; however, there is no obvious difference in surgical remission rate whether patients are pretreated or not. Debulking surgery can also be proposed in very large macroadenomas incompletely controlled by somatostatin agonists or resistant to medical treatment, as it was shown to facilitate somatostatin agonist efficacy in more than 50% cases.     

Perceived difficulty of diabetes treatment in primary care: does it differ by patient ethnicity?

PURPOSE: The purpose of this cross-sectional study was to determine the attitudes of internal medicine physicians toward treating diabetes in different patient ethnic groups and compared with treating common chronic medical conditions in primary care. METHODS: The survey instrument was administered to 55 internal medicine physicians. An e-mail message was sent to each physician with a hyperlink to a site where the survey could be completed. The instrument was a modified, quantitative 10-point scale designed to measure attitudes regarding the difficulty of treating diabetes. RESULTS: Diabetes was perceived to be more difficult to treat than hyperlipidemia and angina. African Americans with diabetes were perceived to be more difficult to treat than Caucasian patients. Difficulty in treating diabetes was comparable to that for hypertension, arthritis, and congestive heart failure. Physicians were confident about treatment efficacy for diabetes and changing diabetes outcomes, but not about the adequacy of time and resources for diabetes treatment. CONCLUSIONS: Diabetes was perceived as a difficult disease to treat, African American patients were more difficult to treat, and time and resources were inadequate for diabetes treatment. To improve diabetes care, there is a need to address these attitudes and concerns of internal medicine physicians.     

Are blood pressure levels taken during a secondary care diabetic clinic likely to be higher than when measured in primary care?

Blood pressure management guidelines are widely available. Our aim was to examine differences in blood pressure on the same subjects in primary and secondary care. We identified 661 diabetic subjects with measurements with the aid of the SAIL databank. Blood pressure in primary care was significantly lower than secondary care.     

Are patients more likely to see physicians of the same sex? Recent national trends in primary care medicine

PURPOSE: Women may prefer female physicians, particularly for preventive health services. We assessed national trends in the proportion of women among patients seeing female physicians, and compared visit characteristics and preventive services among visits to female and male primary care physicians. METHODS: We assessed the characteristics of 92,389 visits from the 1995-2000 National Ambulatory Medical Care Survey, a nationally representative survey of office-based physicians in the United States, using linear and logistic regression. RESULTS: Female physicians were more likely than male physicians to see female patients in the specialties of primary care (73% vs. 56%), psychiatry (72% vs. 54%), dermatology (67% vs. 56%), and pediatrics (52% vs. 46%; P <0.01 for all). In primary care, the difference increased over time, such that by 2000, 78% of visits to female primary care physicians were from women, compared with 56% for male primary care physicians (P <0.01). Female primary care physicians saw younger patients (mean age, 45 vs. 49 years, P = 0.04), reported longer visits (19 vs. 17 minutes, P <0.01), and reported performing more preventive services than did male primary care physicians when seeing female patients, including Papanicolaou testing (11% vs. 4.7%, P <0.01) and mammograms (9% vs. 4%, P <0.01). CONCLUSION: The phenomenon of sex concordance between patient and physician has increased in recent years, particularly in primary care. Nearly four of five patient visits to female primary care physicians are from women, and female physicians report performing more preventive health services for their female patients.     

Are older people willing to give up their place in the queue for cardiac surgery to a younger person?

OBJECTIVES: to measure whether people aged 65 and over living in Britain would be willing to give up their place on the cardiac surgery waiting list for someone younger than them. METHODS: two British surveys, based on random types of people sampled for the Office for National Statistics Omnibus Surveys, identified respondents aged 65 and over for a module on waiting lists. They were asked to imagine they had a heart condition that required surgery, and that they were on an NHS waiting list. They were then asked if they would be prepared to give up their place on the cardiac surgery waiting list to a younger person (aged 45). The study compared responses to one of two relative waiting list time frames (6 and 12 months). SETTING: two national random samples of the British public aged 65 and over. RESULTS: fifty eight per cent and 62% of Omnibus respondents aged 65 and over responded that it was not right to give up their place on the cardiac surgery waiting list for someone younger in relation to a 6 and 12 month wait respectively. Thirty seven per cent and 34% of each group of Omnibus respondents aged 65+ said it was right to give up their place on the cardiac surgery waiting list for someone younger than them, in relation to a 6 and 12 month relative waiting period respectively. Thus the length of the wait had little effect on response among British respondents. The proportions who were willing to cede priority are far less than that reported in a comparable Italian survey. Consistent with the Italian survey, willingness to cede priority increased with age. CONCLUSIONS: most older people in Britain do not wish to cede priority on the waiting list for cardiac surgery to people younger than themselves, although willingness to give up one's place increased with age. The specific time frame did not have an impact on people's responses. The increase in willingness to cede priority with older age could be interpreted as older people valuing themselves less, or that they feel that they have had their 'fair innings' and are willing to give younger people the chance of reaching their age. It could even reflect a cohort effect. It is likely that ageing 'baby boomers' may be even less willing to give up their place in the health service queue and will be more assertive about their right to equity in health care provision.     

How can we increase the involvement of primary health care in the treatment of tobacco dependence? A meta‐analysis

Aims A systematic review of studies testing the effectiveness of educational and practice base strategies to increase the involvement of primary health‐care practitioners in the treatment of tobacco dependence. Data sources MEDLINE, EMBASE, CINAHL and the Cochrane Library (1966–2001). Selection criteria included studies that used randomized or controlled clinical designs, controlled before and after trials and interrupted time‐series designs and that presented objective and interpretable measures of practitioners’ behaviour and biochemically verified patient quit rates. Review methods A meta‐analysis, using a random effects model, of 24 programmes identified in 19 trials. Effect sizes were adjusted by inverse variance weights to control for studies’ sample sizes. Findings Analyses to explain the heterogeneity of effect sizes found that interventions were equally effective in changing practitioners’ screening and advice‐giving rates and their patients’ quit rates. Absolute increases for the intervention above the comparison groups were 15% (95% CI = 7–22) for screening rates, 13% (95% CI = 9–18) for advice‐giving rates and 4.7% (95% CI = 2.5–6.9) for biochemically verified patient quit rates. Practitioners in training programmes were effective in changing their patients’ quit rates but not their own screening rates; educational interventions were more effective than practice‐based interventions. For established practitioners, programmes were effective in changing their screening and advice‐giving rates, but not their patients’ quit rates; a combination of practice‐based and educational interventions were more effective. Conclusions Primary health‐care practitioners can be engaged in the treatment of tobacco dependence to increase equally their screening and advice‐giving rates and their patients’ quit rates with outcomes of considerable public health and clinical significance. The provision of educational interventions for practitioners in training in combination with systematic outreach practice‐based support for established practitioners is likely to be an effective strategy to increase smoking quit rates throughout primary health care.     

Are poor responses to praziquantel for the treatment of Schistosoma mansoni infections in Senegal due to resistance? An overview of the evidence

This paper summarizes and concludes in-depth field investigations on suspected resistance of Schistosoma mansoni to praziquantel in northern Senegal. Praziquantel at 40 mg/kg usually cures 70-90% of S. mansoni infections. In an initial trial in an epidemic S. mansoni focus in northern Senegal, only 18% of the cases became parasitologically negative 12 weeks after treatment, although the reduction in mean egg counts was within normal ranges (86%). Among other hypotheses to explain the observed low cure rate in this focus, the possibility of drug resistance or tolerance had to be considered. Subsequent field trials with a shorter follow-up period (6-8 weeks) yielded cure rates of 31-36%. Increasing the dose to 2 x 30 mg/kg did not significantly improve cure rates, whereas treatment with oxamniquine at 20 mg/kg resulted in a normal cure rate of 79%. The efficacy of praziquantel in this focus could be related to age and pre-treatment intensity but not to other host factors, including immune profiles and water contact patterns. Treatment with praziquantel of individuals from the area residing temporarily in an urban region with no transmission, and re-treatment after 3 weeks of non-cured individuals within the area resulted in normal cure rates (78-88%). The application of an epidemiological model taking into account the relation between egg counts and actual worm numbers indicated that the low cure rates in this Senegalese focus could be explained by assuming a 90% worm reduction after treatment with praziquantel; in average endemic situations, such a drug efficacy would result in normal cure rates. Laboratory studies by others on the presence or absence of praziquantel resistance in Senegalese schistosome strains have so far been inconclusive. We conclude that there is no convincing evidence for praziquantel-resistant S. mansoni in Senegal, and that the low cure rates can be attributed to high initial worm loads and intense transmission in this area.     

Obesity in the united states: Is there a quick fix? Pros and cons of bariatric surgery from the pediatric perspective

Bariatric surgery has become a standard of care for the treatment of severely obese adults who meet National Institutes of Health criteria. Unfortunately, there is a need for weight loss surgery in adolescents. Criteria developed for adolescents are generally more restrictive than those for adults due to concerns about the ability of children to consent for life-altering surgery and the lack of long-term results. Several preliminary series have reported adolescent bariatric procedures with promising results. The two primary bariatric procedures performed on adolescents are Roux-en-Y gastric bypass (RYGB) and adjustable gastric banding (AGB). Each procedure has its advantages and disadvantages. RYGB has the longest follow-up results and is considered the "gold standard." AGB has promising results, is reversible, and can be performed with less morbidity and mortality.     

Raised intraocular pressure (IOP) and perioperative visual loss in laparoscopic colorectal surgery: a catastrophe waiting to happen? A systematic review of evidence from other surgical specialities

Background

Case reports of healthy patients experiencing total perioperative visual loss (POVL) after elective laparoscopic surgery, including colorectal resection, are appearing increasingly frequently in the literature. We reviewed the literature exploring the relationship between patient positioning and intraocular pressure (IOP) across all surgical specialties. This was then applied to the potential risk of developing POVL in patients undergoing laparoscopic colorectal surgery.

Methods

A systematic review of the relevant literature was performed to identify all studies exploring the relationship between intraocular pressure and patient positioning.

Results

Eight relevant studies on both elective patients and healthy non-anaesthetised volunteers in the spinal, neurosurgical and urological fields were identified which explore the changes in IOP according to patient positioning. These all reported significant rises in IOP in both head-down positioning and prone positioning, and the strongest effects were seen in those patients placed in combined head-down and prone position (such as prone jackknife). Rises in IOP were time-dependent in all studies.

Conclusions

Patients undergoing laparoscopic colorectal surgery in a prolonged head-down position are likely to experience raised IOP and thus are at risk of POVL. Those having a laparoscopic abdominoperineal excision with prone positioning for the perineal component are probably those in the greatest danger. Surgeons need to be aware of this under-recognised but potentially catastrophic complication.