Improved Survival with Higher Hematocrits: Where is the Evidence?

The Centers for Medicare and Medicaid Services (CMS) is reviewing Medicare coverage policy for recombinant human erythropoietin (epoetin) therapy. CMS officials are concerned that "Medicare spending on EPO may be higher than necessary without resulting in optimal patient benefit." Approximately 190 end-stage renal disease (ESRD) patients die each day-a mortality rate that has remained essentially unchanged since 1994-despite improvements in the "adequacy of dialysis, vascular access, and anemia management". To date, the evidence cited in support of a survival benefit of epoetin confuses the relationship between treatment response and outcomes with a causal effect of epoetin. A variety of mechanisms may account for a non-causal association between hematocrit and mortality can occur. We conclude that there is no basis for inferring the survival benefits (or detriments) of increasing a patient's hematocrit by adjusting the dosing of epoetin. Furthermore, we note that caution is required in administering large doses of epoetin to unresponsive patients in order to achieve the target hematocrit. A better understanding of the epoetin/survival relationship, well-grounded in science, is needed to provide a basis for CMS to improve its current epoetin policies, and may help to improve patient mortality.     

Rapidly enlarging lump in the neck: is it a tumour?

A rapidly enlarging lump in the neck of an adolescent, is a cause for concern. Amongst the various clinical differential diagnoses, including lymphoma and other malignant lesions, focal myositis is an unusual cause. To date, only two such cases affecting the sternomastoid have been reported worldwide. We report a further similar case.     

Alpha adrenoceptor antagonists in the year 2000: is there anything new?

Selective alpha1-adrenergic blockade is now a well accepted and widely used therapeutic treatment for patients presenting with symptomatic bladder outlet obstruction thought to be associated with benign prostatic hyperplasia. This review summarizes the recent developments in this field relating to the subject of receptor subtype selectivity and the potential relevance of this to clinical usefulness of existing drug therapy. Whilst a number of unanswered questions remain as to the exact mechanisms of both drug action and side-effect profile, nevertheless it is clear that existing clinically available alpha1-antagonists provide a safe, effective and generally well tolerated therapy for patients with lower urinary tract symptoms thought to be associated with benign prostatic obstruction. The implications of the ALLHAT study are discussed.     

Where is the true location of the femoral piriform fossa?

ObjectiveTo analyze knowledge of the anatomic location of the piriform fossa using a questionnaire with anatomic figures.Materials and methodsParticipants taking AO Trauma Brasil courses were requested to complete a questionnaire containing a photograph of the superior surface and a photograph of the lateral surface of the femur and answer a question asking which of four numbered points corresponded to the piriform fossa.ResultsJust 4.5% of respondents correctly chose point 2 (the piriform fossa) in both images, while 75.4% of respondents chose point 4 (the trochanteric fossa) as the correct anatomic structure. The subset of 4th-year residents’ answers was significantly different from those of the other subsets, with 7.5% of correct answers.ConclusionsThe low rate of correct answers indicates a tendency for the respondents to be influenced by illustrations in text books or examples in scientific publications that indicate the site of the piriform fossa incorrectly. Interest in the specialty of traumatology is possibly the reason why the subset of 4th-year residents had a better- than-average rate of correct answers.     

Intra-abdominal measurement techniques: is there anything new?

Intra-abdominal pressure (IAP) measurements are essential to the diagnosis and management of intra-abdominal hypertension (IAH) and abdominal compartment syndrome. A variety of IAP measurement techniques have been described. The intravesicular or "bladder" technique remains the gold standard. This commentary reviews each of the different techniques for IAP measurement and discusses their clinical application. It also explores how IAP is affected by changes in body position, body mass index, and positive end-expiratory pressure (PEEP). IAP should be measured every 4 to 6 hours in patients with risk factors for IAH. Putting patients in the semirecumbent position changes the IAP measurement significantly. The role of prone positioning in unstable patients with IAH remains unclear. PEEP has a small effect on IAP.     

Preventive interventions for back and neck pain problems: what is the evidence?

STUDY DESIGN: A review of controlled trials. OBJECTIVES: To determine which interventions are used to prevent back and neck pain problems as well as what the evidence is for their utility. SUMMARY OF BACKGROUND DATA: Given the difficulty in successfully treating long-term back and neck pain problems, there has been a call for preventive interventions. Little is known, however, about the value of preventive efforts for nonpatients, e.g., in the general population or workplace. METHODS: The literature was systematically searched to locate all investigations that were: 1) specifically designed as a preventive intervention; 2) randomized or nonrandomized controlled trials; and, 3) using subjects not seeking treatment. Outcome was evaluated on the key variables of reported pain, report of injury, dysfunction, time off work, health-care utilization, and cost. Conclusions were drawn using a grading system. RESULTS: Twenty-seven investigations meeting the criteria were found for educational efforts, lumbar supports, exercises, ergonomics, and risk factor modification. For back schools, only one of the nine randomized trials reported a significant effect, and there was strong evidence that back schools are not effective in prevention. Because the randomized trials concerning lumbar supports were consistently negative, there is strong evidence that they are not effective in prevention. Exercises, conversely, showed stable positive results in randomized controlled trials, giving consistent evidence of relatively moderate utility in prevention. Because no properly controlled trials were found for ergonomic interventions or risk factor modification, there was not good quality evidence available to draw a conclusion. CONCLUSIONS: The results concerning prevention for subjects not seeking medical care are sobering. Only exercises provided sufficient evidence to conclude that they are an effective preventive intervention. There is a dire lack of controlled trials examining broad-based multidimensional programs. The need for high quality outcome studies is underscored.     

Comminuted fractures of the radial head and neck: is fixation to the shaft necessary?

Mason type III fractures of the radial head are treated by open reduction and internal fixation, resection or prosthetic joint replacement. When internal fixation is performed, fixation of the radial head to the shaft is difficult and implant-related complications are common. Furthermore, problems of devascularisation of the radial head can result from fixation of the plate to the radial neck. In a small retrospective study, the treatment of Mason type III fractures with fixation of the radial neck in 13 cases (group 2) was compared with 12 cases where no fixation was performed (group 1). The mean clinical and radiological follow-up was four years (1 to 9). The Broberg-Morrey index showed excellent results in both groups. Degenerative radiological changes were seen more frequently in group 2, and removal of the implant was necessary in seven of 13 cases. Post-operative evaluation of these two different techniques revealed similar ranges of movement and functional scores. We propose that anatomical reconstruction of the radial head without metalwork fixation to the neck is preferable, and the outcome is the same as that achieved with the conventional technique. In addition degenerative changes of the elbow joint may develop less frequently, and implant removal is not necessary.