Patients with low levels of high-density lipoprotein cholesterol: to treat or not to treat?

Clinical evidence indicates that a low level of high-density lipoprotein cholesterol (HDL-C) is a major risk of atherosclerosis. Raising HDL-C reduces this risk significantly, making HDL-C levels an important target of treatment for dyslipidaemia, especially in pre-existent atherosclerosis. HDL-C is protective against atherosclerosis, largely due to its function of reverse cholesterol transport. Additionally, some important roles include fibrinolysis, antioxidant functions, and reduction of platelet aggregability. A number of agents potentially modify HDL favourably. Niacin is the most potent HDL-C raising agent currently available in clinical practice, followed by fibrates. CETP inhibitors show greater HDL-C rising, but are still used in trial settings only. HDL mimetic agents are another group of agents that offer much promise. Clinical outcome data are awaited for these newer therapeutic agents.     

Preterm delivery and low maternal serum cholesterol level: Any correlation?

Background:

The study assessed whether low maternal serum cholesterol during early pregnancy is associated with preterm delivery.

Patients and Methods:

It was a prospective observational cohort study involving pregnant women at gestational age of 14-20 weeks over a period of 12 months. Blood samples were obtained to measure total serum cholesterol concentrations and the sera were then analysed enzymatically by the cholesterol oxidase: p-aminophenazone (CHOD PAP) method.

Results:

The study showed an incidence of 5.0% for preterm delivery in the low risk study patients. Preterm birth was 4.83-times more common with low total maternal cholesterol than with midrange total cholesterol (11.8% versus 2.2%, P = 0.024).

Conclusion:

Low maternal serum cholesterol (hypocholesterolaemia) is associated with preterm delivery. Optimal maternal serum cholesterol during pregnancy may have merit, therefore pregnant women should be encouraged to follow a healthy, balanced diet.     

Is physician detection associated with thinner melanomas?

CONTEXT: In cutaneous melanoma, tumor depth remains the best biologic predictor of patient survival. Detection of prognostically favorable lesions may be associated with improved survival in patients with melanoma. OBJECTIVE: To determine melanoma detection patterns and relate them to tumor thickness. DESIGN: Interview survey. SETTING AND PATIENTS: All patients with newly detected primary cutaneous melanoma at the Melanoma Center, Johns Hopkins Medical Institutions, between June 1995 and June 1997. MAIN OUTCOME MEASURE: Tumor thickness grouped according to detection source. RESULTS: Of the 102 patients (47 men, 55 women) in the study, the majority of melanomas were self-detected (55%), followed by detection by physician (24%), spouse (12%), and others (10%). Physicians were more likely to detect thinner lesions than were patients who detected their own melanomas (median thickness, 0.23 mm vs 0.9 mm; P<.001). When grouped according to thickness, 11 (46%) of 24 physician-detected melanomas were in situ, vs only 8 (14%) of 56 patient-detected melanomas. Physician detection was associated with an increase in the probability of detecting thinner (< or =0.75 mm) melanomas (relative risk, 4.2; 95% confidence interval, 1.4-11.1; P=.01). CONCLUSIONS: Thinner melanomas are more likely to have been detected by physicians. Increased awareness by all physicians may result in greater detection of early melanomas.     

Are physicians' perceptions of healthcare quality and practice satisfaction affected by errors associated with electronic health record use?

Background

Electronic health record (EHR) adoption is a national priority in the USA, and well-designed EHRs have the potential to improve quality and safety. However, physicians are reluctant to implement EHRs due to financial constraints, usability concerns, and apprehension about unintended consequences, including the introduction of medical errors related to EHR use. The goal of this study was to characterize and describe physicians'' attitudes towards three consequences of EHR implementation: (1) the potential for EHRs to introduce new errors; (2) improvements in healthcare quality; and (3) changes in overall physician satisfaction.

Methods

Using data from a 2007 statewide survey of Massachusetts physicians, we conducted multivariate regression analysis to examine relationships between practice characteristics, perceptions of EHR-related errors, perceptions of healthcare quality, and overall physician satisfaction.

Results

30% of physicians agreed that EHRs create new opportunities for error, but only 2% believed their EHR has created more errors than it prevented. With respect to perceptions of quality, there was no significant association between perceptions of EHR-associated errors and perceptions of EHR-associated changes in healthcare quality. Finally, physicians who believed that EHRs created new opportunities for error were less likely be satisfied with their practice situation (adjusted OR 0.49, p=0.001).

Conclusions

Almost one third of physicians perceived that EHRs create new opportunities for error. This perception was associated with lower levels of physician satisfaction.     

Back pain associated with osteoporosis

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Splenic abscess associated with bacterial endocarditis

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Are Partin tables suitable for Chinese patients with prostate cancer?

Background  Recently, the number of patients with prostate cancer who needed to be treated with radical prostatectomy increased rapidly in China. There is still a difference between clinical staging and the post-operative final pathologic staging; hence, an excellent tool for accurately predicting the pathologic stages of prostate cancer is needed urgently in clinical practice. The Partin tables are the most popular and widely used tool for predicting the pathologic stages of prostate cancer because of its high accuracy and ease of implementation. The aim of this study was to externally validate the accuracy of the three versions of the Partin tables in predicting the post-operative pathologic stages in Chinese patients with prostate cancer.

Methods  We retrospectively analyzed the data from 203 patients with prostate cancer who underwent radical prostatectomies between June 2000 and May 2012. The accuracies of the three versions of the Partin tables in predicting the post-operative pathologic stages in Chinese patients with prostate cancer were evaluated using the area under the receiver operating characteristic curve (AUC).

Results  Using the 1997, 2001, and 2007 Partin tables for predicting the current cases, the AUC of organ confinement (OC) was 0.877, 0.788, and 0.726; the AUC of extracapsular extension (ECE) was 0.525, 0.615, and 0.608; the AUC of seminal vesicle invasion (SVI) was 0.875, 0.649, and 0.820; and the AUC of pelvic lymph node invasion (LNI) was 0.808, 0.758, and 0.735 respectively.

Conclusions  The accuracies of the three versions of Partin tables in predicting OC, SVI, and LNI were good, especially the 2001 Partin table for SVI. In contrast, the accuracy of the three versions of the Partin tables in predicting ECE was fair. The 1997 Partin table was much better than the 2007 table in predicting OC, and the 2001 table in predicting SVI. The 2007 Partin table did not show any advantages.

     

Cholesterol-lowering therapy with pravastatin in patients with average cholesterol levels and established ischaemic heart disease: is it cost-effective?

OBJECTIVE: To measure the cost-effectiveness of cholesterol-lowering therapy with pravastatin in patients with established ischaemic heart disease and average baseline cholesterol levels. DESIGN: Prospective economic evaluation within a double-blind randomised trial (Long-Term Intervention with Pravastatin in Ischaemic Disease [LIPID]), in which patients with a history of unstable angina or previous myocardial infarction were randomised to receive 40 mg of pravastatin daily or matching placebo. PATIENTS AND SETTING: 9014 patients aged 35-75 years from 85 centres in Australia and New Zealand, recruited from June 1990 to December 1992. MAIN OUTCOME MEASURES: Cost per death averted, cost per life-year gained, and cost per quality-adjusted life-year gained, calculated from measures of hospitalisations, medication use, outpatient visits, and quality of life. RESULTS: The LIPID trial showed a 22% relative reduction in all-cause mortality (P < 0.001). Over a mean follow-up of 6 years, hospital admissions for coronary heart disease and coronary revascularisation were reduced by about 20%. Over this period, pravastatin cost $A4913 per patient, but reduced total hospitalisation costs by $A1385 per patient and other long-term medication costs by $A360 per patient. In a subsample of patients, average quality of life was 0.98 (where 0 = dead and 1 = normal good health); the treatment groups were not significantly different. The absolute reduction in all-cause mortality was 3.0% (95% CI, 1.6%-4.4%), and the incremental cost was $3246 per patient, resulting in a cost per life saved of $107 730 (95% CI, $68 626-$209 881) within the study period. Extrapolating long-term survival from the placebo group, the undiscounted cost per life-year saved was $7695 (and $10 938 with costs and life-years discounted at an annual rate of 5%). CONCLUSIONS: Pravastatin therapy for patients with a history of myocardial infarction or unstable angina and average cholesterol levels reduces all-cause mortality and appears cost effective compared with accepted treatments in high-income countries.     

Psychophysiological reactions associated with qigong therapy.

Qigong as a part of the traditional Chinese medicine is similar to western "meditation", Indian "Yoga" or Japanese "Zen", which can all be included in the category of traditional psychotherapy. A series of physiological and psychological effects occur in the course of Qigong tranining, but inappropriate training can lead to physical and mental disturbances. Physiological effects include changes in EEG, EMG, respiratory movement, heart rate, skin potential, skin temperature and Finger tip volume, sympathetic nerve function, function in stomach and intestine, metabolism, endocrine and immunity systems.Psychological effects are motor phenomena and perceptual changes: patients experienced warmness, chilliness, itching sensation in the skin, numbness, soreness, bloatedness, relaxation,tenseness, floating, dropping, enlargement or constriction of the body image, a sensation of rising to the sky, falling off, standing upside down, playing on the swing following respiration, circnlation of the intrinsic Qi, elec     

Thymoma associated with severe diarrhoea and anaemia

About 40% of patients with thymoma have one or ,more paraneoplastic syndromes, including myasthenia gravis, pure red cell aplasia （PRCA） or hypogammaglobulinaemia, but Good syndrome occurs in only 5% of these conditions. To our knowledge, only 11 patients （including our cases） of thymoma accompanied with PRCA and Good syndrome have been reported, however, no such case was reported in China before 2000.     

Are district general hospital patients with unstable angina at a disadvantage?

Objective: To determine whether patients with non-ST elevation acute coronary syndromes requiring coronary angiography and revascularisation have inferior access to these services if admitted to district general hospitals (DGHs) compared with similar patients admitted to a base hospital containing a tertiary cardiac centre. Design: Prospective, consecutive monitoring of all patients with acute coronary syndromes accepted by the tertiary cardiac centre for angiography and revascularisation over a three month period (1 April to 30 June 2002). Participants: All patients accepted for angiography from DGHs and from within the base hospital with a diagnosis of acute coronary syndromes. Setting: Tertiary cardiac facility (Manchester Heart Centre at Manchester Royal Infirmary (MRI)). Main outcome measure: Time waited from referral to angiography and revascularisation. Results: A total of 184 patients with a diagnosis of non-ST elevation acute coronary syndromes underwent angiography with a view to revascularisation. Of these, 89 (48%) were admitted initially to MRI and 95 (52%) were admitted to a feeder DGH. DGH patients waited significantly longer from admission to angiography than MRI patients (median 13 days (25th-75th percentiles 7–19) v 5 days (3–8) respectively; p<0.0005). DGH patients therefore also waited longer from admission to revascularisation (15 days (6–20) v 6 days (3–9) respectively). Once transferred into the Manchester Heart Centre, DGH patients underwent angiography within a median of 1 day (1–2). More DGH patients than those from MRI underwent both coronary artery bypass grafting (21 (22%) v 8 (9%) respectively; p=0.015) and percutaneous coronary intervention (44 (46%) v 32 (36%) respectively; p=NS). Conclusion: Patients admitted to feeder DGHs with non-ST elevation acute coronary syndromes wait significantly longer for access to invasive coronary assessment and revascularisation than similar patients admitted in the hospital that incorporates the tertiary cardiac centre. This inequity of access is determined by postcode rather than clinical priority.     

Perioperative morbidity and mortality of patients with colorectal cancer

Objective To investigate the perioperative morbidity and mortality of patients with colorectal cancer. Methods Postoperative morbidity and mortality were analyzed in 903 colorectal cancer patients of Peking University Third Hospital from 1992 to 2005. Results There was colonic carcinoma in 518 cases （CC 57.4 % ） rectal carcinoma in 385 casec （RC 42.6 % ）. The overall pefioperative morbidity rate was 21.8 %, with 18.3 % in CA,     

Are doctors altruistic?

There is a growing belief in the US that medicine is an altruistic profession, and that physicians display altruism in their daily work. We argue that one of the most fundamental features of medical professionalism is a fiduciary responsibility to patients, which implies a duty or obligation to act in patients' best medical interests. The term that best captures this sense of obligation is "beneficence", which contrasts with "altruism" because the latter act is supererogatory and is beyond obligation. On the other hand, we offer several examples in which patients act altruistically. If it is patients and not the doctors who are altruistic, then the patients are the gift-bearers and to that extent doctors owe them gratitude and respect for their many contributions to medicine. Recognising this might help us better understand the moral significance of the doctor-patient relationship in modern medicine.