Annual mammography screening: is it necessary?

Recent recommendations from the U.S. Preventative Services Task Force suggest that screening mammography for women should be biennial starting at age 50 years and continue to age 74 years. With these recommendations in mind, we proposed a study to evaluate women at our institution in whom breast cancer is diagnosed within 1 year of a previously benign mammogram. A retrospective chart review was performed over a 4-year period. Only patients who had both diagnostic mammograms and previous mammograms performed at our institution and a pathologic diagnosis of breast cancer were included. Benign mammograms were defined as either Breast Imaging Reporting And Data System 1 or 2. Analysis of the time elapse between benign mammogram and subsequent mammogram indicative of the diagnosis of breast cancer was performed. A total of 205 patients were included. The average age was 64 years. From our results, 48 patients, 23 per cent of the total, had a documented benign mammogram at 12 months or less before a breast cancer diagnosis. One hundred forty-three (70%) patients had a benign mammogram at 18 months or less prior. This study raises concern that 2 years between screening mammograms may delay diagnosis and possible treatment options for many women.     

The female ACL: why is it more prone to injury?

Multiple factors are responsible for ACL tears. The key factor in the gender discrepancy appears to be dynamic, not static, and proximal, not distal. The factors involved in evaluating the female ACL are multiple. However, it is the dynamic movement patterns ot hip and knee position with increased flexion and a coordinated proximal muscle firing pattern to keep the body in a safe landing position that are the most critical factors. An ACL injury at an early age is a life-changing event. We can very successfully reconstruct and rehabilitate an ACL, but we cannot stop there. We must now go into the prevention arena. In the United States there is tremendous variation in the exposure and acquisition of skills of physical activities in our youth. Today, children are often playing inside, using computers and watching television-missing out on the opportunity to learn safe movement patterns. Therefore, physical movement classes should occur very early in life, teaching children to land safely and in control, similar to the cry of "get down, stay down" routinely heard during youth soccer. Similarly, specific strength training programs can address landing as well as foot movements during cutting in basketball. Coaches should issue stern warnings when athletes demonstrate a high-risk movement patterns such as one-leg landings, out-of-control baseline landings, or straight-leg landings. The warnings may serve to keep the athlete from "touching the hot stove again" for fear of getting burned. No athlete feels she will be the one to get injured. Therefore, prospective analysis is likely to be received more warmly by the athletes if the program is presented with an emphasis on performance improvement rather than injury prevention. With increased participation in these programs, multiple-center analysis will have the power necessary to determine which factors significantly predispose athletes to ACL injury. The future for injury prevention is bright. We must rise to the challenge.     

Diagnosing endometrial hyperplasia: why is it so difficult to agree?

Current World Health Organization classification of endometrial hyperplasia is problematic because of poor diagnostic reproducibility. We sought to determine factors that cause diagnostic disagreement in a review of 2601 endometrial specimens. Blinded random specimens of normal endometrium, hyperplasias, and carcinoma were reviewed by 2 pathologists, with review by a third pathologist in cases with disagreement. All cases of endometrial hyperplasia or carcinoma were scored for degree of glandular crowding, architectural complexity, and cytologic atypia. Sample adequacy, hyperplasia volume, presence of metaplasia, or endometrial polyp were also scored. The overall kappa for agreement was 0.71, with a lower kappa of 0.36 when cases called "no hyperplasia" were excluded. The percent specific agreement was 90.3% for no hyperplasia, 31.1% for simple hyperplasia, 51.1% for complex hyperplasia, 49.8% for atypical hyperplasia, and 57.5% for adenocarcinoma. Cases categorized as "low volume hyperplasia" had more diagnostic disagreement than "high volume," (62% vs. 39%, P=0.003). Similarly, cases called "scant" had more diagnostic disagreement than "not scant" (65% vs. 57%, P=0.013). The histologic feature associated with the most diagnostic disagreement was cytologic atypia (P<0.0001). Architectural crowding, architectural complexity, or the presence of a polyp were all associated with diagnostic disagreement (P<0.0001). High diagnostic disagreement in endometrial hyperplasia is related to both sample adequacy and interpretation of histologic features present. Although obtaining additional tissue may increase diagnostic reproducibility, differences in interpretation of key histologic features like cytologic atypia remain major factors contributing to diagnostic disagreement.     

Use of the foot abduction orthosis following Ponseti casts: is it essential?

The purpose of this study was to evaluate the need for the use of a foot abduction orthosis (FAO) in the treatment of idiopathic clubfeet using the Ponseti technique. Forty-four idiopathic clubfeet were treated with casting using the Ponseti method followed by FAO application. Compliance was defined as full-time FAO use for 3 months and part-time use subsequently. Noncompliance was failure to fulfill the criteria during the first 9 months after casting. Feet were rated according to the Dimeglio and Pirani scoring systems at initial presentation, at the time of FAO application, and at 6 to 9 months of follow-up. At the time of application, no significant differences in scores were found between the groups. At follow-up, the compliant group's scores were significantly (P < 0.01) better than those of the noncompliant group. From the time of application to follow-up, for the compliant group, the Dimeglio scores improved significantly (P = 0.005). For the noncompliant group, the Dimeglio scores deteriorated significantly (P = 0.001). The feet of patients compliant with FAO use remained better corrected than the feet of those patients who were not compliant. Proper use of FAO is essential for successful application of the Ponseti technique.     

Comparative effectiveness research: what is it and why do we need it in nephrology?

The USA leads other industrialized countries in health care spending but lags behind in terms of health outcomes. There has been growing interest in comparative effectiveness research (CER) as a means to identify best practices to create a more efficient and effective health care system. Two key concepts of CER are that it should (i) compare two or more alternative tests, therapies or procedures and (ii) be conducted in persons, clinical settings and conditions that are representative of the real world. The goal of CER is to provide evidence for clinicians, patients, policy makers and others to make informed decisions that will ultimately improve the overall health of specific subgroups and of the population as a whole. In this narrative review, we first describe the strengths and limitations of various types of studies that constitute CER, including randomized clinical trials, observational studies and systematic reviews, providing examples from the nephrology literature. Because of the concerns regarding confounding in observational CER, we also provide an overview of methods to reduce confounding in these types of studies. Finally, we will discuss why CER pertaining to kidney disease care needs to be a top priority in order to move our field from a largely opinion-based specialty to an evidence-based specialty.     

Urinary ultrasonography in screening incidental renal cell carcinoma: is it obligatory?

Purpose  

To analyze the rate of incidental renal carcinoma in patients with no upper urinary tract symptoms (UUTS) or hematuria depending on the sonography reports and medical records of the patients and to determine whether there is a need for routine US screening for RCC.     

Hypertension in renal parenchymal disease: why is it so resistant to treatment?

The association between hypertension and chronic renal disease is well known. The pathogenesis of hypertension in patients with chronic kidney disease (CKD) is complex and multifactorial, which may explain why it is resistant to treatment. The traditional paradigm is that hypertension in CKD is due either to an excess of intravascular volume (volume dependent) or to excessive activation of the renin-angiotensin system in relation to the state of sodium/volume balance (renin-dependent hypertension). This review focuses on the importance of less established mechanisms, such as increased activity of the sympathetic nervous system, increased endothelin production, decreased availability of endothelium-derived vasodilators and structural changes of the arteries, renal ischemia, and sleep apnea.     

A third renal transplantation: is it relevant and is it worth it?

INTRODUCTION: The aim of this retrospective study was to determine the outcome of third cadaveric renal transplantations performed between 1989 and 2004 among a cohort of 35 patients whose immunosuppression included induction therapy and calcineurin inhibitors. Most patients were highly sensitized with 1 (0-4) HLA (classes I + II) incompatibility between donor and recipient. RESULTS: The median follow-up time was 57 months (range, 1-190). Fourteen patients experienced delayed graft function that required posttransplantation hemodialysis. The current patient and graft survival rates were 91.4% and 82.8%, respectively. At last follow-up, 6 grafts had been lost: 1 due to primary nonfunction; 1 due to an urinary leak (day 45); 2 deaths with functioning grafts; and 2 chronic allograft nephropathies (CAN) at 85 and 60 months posttransplantation, respectively. Among the 10 patients who experienced acute rejection episodes, half were steroid-sensitive, whereas the others required OKT3 therapy. Overall, when excluding the 2 patients who presented with early loss of their grafts, 13 of 33 patients (39.4%) developed CAN, which led to the graft loss in only 2 cases. The mean creatinine clearance was 57 +/- 23 mL/min at year 5. Of the 35 recipients, 12 (34.3%) developed graft/perigraft complications, among whom 10 (83.3%) required treatment. The most frequent complication was lymphocele (M = 4; 11.4%) or infections that led to rehospitalization (n = 17). CONCLUSION: Results from third transplantations were encouraging. Thus, despite the organ shortage, a third graft was worth it!     

Establishing hand preference: why does it matter?

Hand preference has been associated with psychological and physical well-being, risk of injury, pathological irregularities, longevity, and cognitive function. To determine hand preference, individuals are often asked what hand they use to write with, or what hand is used more frequently in activities of daily living. However, relying only on one source of information may be misleading, given the strong evidence to support a disassociation between self-reported hand preference and outcomes of hand performance assessments. This brief communication is intended to highlight the various methods used to determine hand preference, to discuss the relationship between hand preference inventories and performance measures and to present some recent findings associated with hand preference and musculoskeletal disorders.     

Evidence-based orthopaedics: is it possible?

EBM is referred to as the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. This article describes the history and practice of evidence-based medicine.