Renal artery stenosis: when to intervene?

Indications and timing of revascularization for atherosclerotic renal artery stenosis are topics of considerable controversy. Labile hypertension, progressive renal failure, and flash pulmonary edema may be strong indications for revascularization, yet revascularization may carry significant morbidity and mortality risks. Medical therapy alone, however, may also risk deterioration of renal function with worsening morbidity and mortality. We report a case of renal artery stenosis illustrating some of the complexities of decision-making, the limitations of angiography, and the importance of physiologic testing.     

Trend of an osteoporosis curative medicine--Who uses what from when to when how?

About the point of which medicine to use how in the medical treatment of osteoporosis, the large-scale clinical trial performed in Europe and America has been arranging. Especially, about calcium, vitamin D, estrogen, and bisphosphonates medicine can be used now based on the evidence about them. The necessity of medical treatment for the patient diagnosed as osteoporosis according to the criteria established by osteoporosis congress is guaranteed. However, when considering the necessity for prevention of osteoporosis, we would like to know the view about medicating osteopenia group, but there are few bases that for the moment it is important. Moreover, "up to when" in the point whether medical treatment is required, we have to wait for the report of the clinical test of medicine medication over a long period of time which is performed now. However, it is foundations to continue medicine medication as much as possible now, if effective. Although it became clear in estrogen medical treatment that a risk is higher than a benefit by medication examination over a long period of time, as well as this, It is necessary to discuss the benefit and the economic effect of an osteoporosis curative medicine.     

Management of severe acute to fulminant hepatitis B: to treat or not to treat or when to treat?

Despite a decline in cases of acute hepatitis B and the low hepatitis B virus (HBV) chronicity rates in adults, still some patients progress to HBV-related fulminant liver failure. In this review, we discuss treatment options that may prevent the progression of severe acute hepatitis B to fulminant liver failure and death. In severe acute HBV with prolonged prothrombin time and increased bilirubin, interferon failed to be effective while antiviral treatment, particularly with lamivudine, appears to improve survival (mean survival almost 80%). Outcome without antiviral therapy has remained considerably poor, whereas there is no convincing evidence of amelioration of HBV-targeted immunity. Of note, most patients who died or required transplantation despite lamivudine therapy, were started on lamivudine at advanced stages compared with those survived. This suggests that prompt and timely antiviral therapy is crucial. Owing to the abovementioned results the design of randomized placebo-control trials in the setting of severe acute hepatitis B seems unethical. On the contrary, the design of multicentre double-blind randomized trials to compare the efficacy between lamivudine and entecavir or even tenofovir in acute severe HBV cases is ideally needed, but these studies appear to be very difficult to perform considering that these cases are not frequent and therefore, it is almost impossible to have two arms adequately numerous and homogenous for statistical evaluation. Thus, in the absence of solid evidence based data, the hepatologists could treat their patients with severe acute hepatitis B with lamivudine or the most potent antivirals entecavir or tenofovir.     

How to investigate a child with excessive growth?

The diagnostic approach to tall stature in children is based on collecting birth data (macrosomia), sizes and family puberty, a family history of constitutional or pathological tall stature, search for a delay of development, dysmorphia, disproportion, analysis of the growth velocity (normal or accelerated), general examination and assessment of puberty, and bone age. When there is a history of psychomotor retardation, a family history of pathological tall stature, or a disproportion in the clinical examination, the genetic causes of tall stature will be mentioned. The most frequent causes are Marfan syndrome and similar, Sotos syndrome, Beckwith-Wiedemann syndrome, Klinefelter syndrome, and MEN2B. There are many genetic syndromes with tall stature, justifying consultation with the geneticist. When the speed of growth is accelerated, first of all it evokes puberty and early pseudopuberty, obesity and acromegaly. Finally, when the growth velocity is regular, and the parents are of tall stature, it evokes constitutional tall stature: this is the most frequent diagnosis, to retain after having rejected pathological tall statures.     

Two forms of reactive arthritis?

Inflammatory arthritides developing after a distant infection have so far been called reactive or postinfectious, quite often depending on the microbial trigger and/or HLA-B27 status of the patient. For clarity, it is proposed that they all should be called reactive arthritis, which, according to the trigger, occurs as an HLA-B27 associated or non-associated form. In addition to the causative agents and HLA-B27, these two categories are also distinguished by other characteristics. Most important, HLA-B27 associated arthritis may occur identical to the Reiter's syndrome with accompanying ureteritis and/or conjunctivitis, whereas in the B27 non-associated form this has not been clearly described. Likewise, only the B27 associated form belongs to the group of spondyloarthropathies.     

Biological false reactive VDRL tests: when to re-test?

Syphilis serology is a basic screening test for the workers who want to go abroad. Many countries reject migrant workers who have reactive syphilis serology. Biological false reactives warrant repeated syphilis serology. We prospectively studied 30 patients (25 males and 5 females) who had biological false reactive VDRL tests (VDRL reactive, confirmatory TPHA negative). Affirmative tests for syphilis serology for all cases were performed every two weeks. On follow-up, the expected range (95% CI) for seroconversion was between 9.25 and 10.49 weeks. Most cases (25 cases) completely returned to the VDRL non-reactive stage within 10 weeks; three cases completely returned within 6 weeks; 2 cases completely returned within 14 weeks. It is recommended that repeat syphilis serology be conducted 10 weeks after an initial biological false reactive VDRL test.     

Colonoscopy screening in the elderly: when to stop?

OBJECTIVES: The age to begin colorectal cancer (CRC) screening is based on the risk of neoplasia and is published in screening guidelines. The age to stop screening is unknown but should be based, in part, on the same principle. The purpose of this study was to establish whether the prevalence of neoplasia detected by colonoscopy diminished with advancing age, to warrant ceasing colonoscopic screening. METHODS: The endoscopic and pathology reports of all asymptomatic subjects undergoing colonoscopy for the purpose of CRC screening or an evaluation of abdominal pain or change in bowel habits between 1997 and 2000 were reviewed. A multivariate logistic regression analysis was used to assess the effect of age, gender, and indication for examination on the prevalence of neoplasia, as well as on having more than two adenomas, advanced adenomas (tubulovillous, villous, severe dysplasia, or size > or = 1 cm), and invasive cancers. RESULTS: A total of 915 patients were included. Of these, 50% were male, with a mean age of 65 yr (range 50-100). Neoplasia peaked in the seventh decade, with a fall thereafter (p = 0.009). Numerous adenomas, advanced adenomas, and invasive cancers increased with age. The yield for overall neoplasia, advanced adenomas, and more than two adenomas was higher in the screening group than in the symptomatic group. More invasive cancers were found in the symptomatic group compared with the asymptomatic group, but this did not achieve statistical significance (4 vs 1, p = 0.44). CONCLUSIONS: The prevalence of advanced neoplasia continues to increase with age. Subjects undergoing colonoscopy for screening had a greater risk for neoplasia than did subjects with symptoms. There is no decline in yield of advanced neoplasia to justify stopping screening colonoscopy in the elderly.     

Diagnostic approach to faecal incontinence: What test and when to perform?

Faecal incontinence (FI) is a debilitating common end result of several diseases affecting the quality of life and leading to patient disability, morbidity, and increased societal burden. Given the various causes of FI, it is important to assess and identify the underlying pathomechanisms. Several investigatory tools are available including high-resolution anorectal manometry, transrectal ultrasound, magnetic resonance imaging, and electromyography. This review article provides an overview on the causes and pathophysiology of FI and the author’s perspective of the stepwise investigation of patients with FI based on the available literature. Overall, high-resolution anorectal manometry should be the first investigatory tool for FI, followed by either transrectal ultrasound or magnetic resonance imaging for anal internal sphincter and external anal sphincter injury, respectively.     

Surgery Insight: carotid endarterectomy--which patients to treat and when?

Over the past 15 years, we have witnessed a resurgence of surgery for prevention of ischemic stroke. Landmark trials including the North American Symptomatic Carotid Endarterectomy Trial and the European Carotid Surgery Trial have explored the role of carotid endarterectomy in this context, comparing the procedure with best medical treatment in patients with high-grade stenosis of the internal carotid artery and transient ischemic attack or minor nondisabling stroke in the same territory. Here, we discuss the lessons learnt from these trials, and review the Asymptomatic Carotid Atherosclerosis Study and the Asymptomatic Carotid Surgery Trial, which attempted to resolve the rather vexing issue of surgical treatment for patients with asymptomatic internal carotid artery stenosis. We also review the best medical treatment for patients undergoing carotid endarterectomy in the perioperative period, and examine the risk of ischemic stroke after CABG surgery, both when this procedure is performed alongside endarterectomy and when CABG surgery and endarterectomy are performed as a two-staged procedure.     

Beta blockers in arrhythmias: when and where to use?

Beta blockers are often the first line of medications used in treatment of arrhythmias. Their role has been established in treatment of Supraventricular tachycardia (SVT) and Ventricular tachyarrhythmias (VT). Beta Blockers are also used as prophylactic medications in SVT, VT and Sudden Cardiac Arrest survivors. They are important components of treatment in the management of VT storms, Atrial Fibrillation, arrhythmias during pregnancy, arrhythmias associated with congenital heart disease, Long QT syndrome, arrhythmias in cardiomyopathies and post-cardiac surgery arrhythmias.The choice of drug, dose and route of administration depends on the type of arrhythmia and clinical presentation and demographics of the patient.