Hypertension in pregnancy: is it time for a new approach to treatment?

Hypertensive disorders represent major causes of pregnancy-related maternal mortality worldwide. The current definition and treatment recommendations for elevated blood pressure (BP) during pregnancy in the United States have remained unchanged for many years, unlike the recommendations for hypertension treatment in the general population. Clinical studies have provided convincing evidence that women with hypertensive pregnancy disorders are at both immediate and long-term risk for cardiovascular complications; these findings suggest that consideration be given to lowering the presently recommended BP thresholds, both for the initiation of therapy and for therapeutic targets, and to simplifying the approach to the management of elevated BP in pregnancy. This review focuses on the current treatment strategies for hypertensive pregnancy disorders, new developments in the field of hypertension, in general, and in pregnant patients, in particular, and their potential impact on contemporary BP goals and the use of specific antihypertensive medications in pregnancy.     

Implantable ventricular assist devices: is it time to introduce them in Canada?

BACKGROUND: Implantable left ventricular assist devices (LVAD) are increasingly used in Europe and the United States. Any decision to use them in Canada requires estimates of their clinical value and costs. MATERIALS AND METHODS: No randomized controlled trials are available. Clinical value and costs, concerning principally the HeartMate and Novacor devices, were estimated based on reports of uncontrolled case series obtained through MEDLINE (1993 to 1999), review articles, three technology assessments and data supplied by the manufacturers. RESULTS AND DISCUSSION: Reasonably trouble-free device function can be expected for three to four years. The principal application is as a bridge to transplantation. Rarely, the heart recovers without transplantation. Use as 'permanent' support of the failing heart is still contentious. Approximately 70% of patients with an implanted LVAD survive until recovery or transplantation. Complications are hemorrhage, principally postoperative, 20% to 44%; thromboembolism, ranging from 5% to 15% for the HeartMate to 12% to 37% for Novacor; and significant infection, 50%. Quality of life is slightly inferior to that of patients with transplanted hearts. The direct cost to the health care system of installation is approximately $138,000. As a bridge to transplantation, the estimated cost effectiveness of elective interventions is $91,000 to $126,000 per life-year saved ($117,000 to $186,000, discounted at 5%), and as a permanent alternative to transplantation, the cost per life-year is $52,000 to $60,000 ($50, 000 to $58,000, discounted at 5%), according to circumstances. As a bridge to 50 transplantations per year, the approximate annual cost would be $7 to $13 million (exclusive of transplantation costs). As 'permanent' support for 7000 patients per year, the approximate cost would be $2,661 million per year. CONCLUSIONS: Limited application in a limited number of centres with collection of all data is justifiable at this stage.     

Serological markers for coeliac disease: is it time to change?

BACKGROUND: Anti-gliadin and anti-endomysium antibodies are useful markers in the screening and follow-up of coeliac disease. The recent finding that tissue transglutaminase is the main auto-antigen of anti-endomysium has led to the discovery of anti-tissue transglutaminase antibodies. AIM: To compare, in a prospective study, the diagnostic accuracy of anti-tissue transglutaminase, anti-gliadin and anti-endomysium antibodies in a large series of adult patients. METHODS: The study involved 80 consecutive subjects undergoing upper gastrointestinal tract endoscopy for suspected coeliac disease (subsequently confirmed in 40 cases), 195 coeliac patients on a gluten-free diet, and 70 patients with different gastrointestinal disor ders and normal duodenal histology. Anti-gliadin, anti-endomysium and anti-tissue transglutaminase antibodies levels were measured using commercial kits. RESULTS: The diagnostic sensitivity and specificity of anti-gliadin, anti-endomysium and anti-tissue transglutaminase antibodies were, respectively, 95% and 89.1%, 100% and 97.3%, and 100% and 98.2%: the agreement between the markers was substantial or almost perfect. In terms of follow-up, the positivity of the markers varied according to the strict adherence to, and duration of the gluten-free diet; the agreement between antiendomysium and anti-tissue transglutaminase antibodies was almost perfect. CONCLUSIONS: Anti-endomysium and anti-tissue transglutaminase antibodies are both highly efficient for routine laboratory screening: the choice of one or the other will depend on the available facilities. However, neither can replace intestinal biopsy for general population screening because, in this case, their respective positive predictive values are only 15.7% and 21.8%. During follow-up, anti-gliadin retain their value as an early predictor of gluten ingestion.     

Selective non-antibiotic treatment in sigmoid diverticulitis: is it time to change the traditional approach?

Background

A growing body of knowledge is calling into question the use of antibiotics in acute diverticulitis (AD). Moreover, recent studies provide evidence regarding the security of treating patients with AD as outpatients. The aim of this study was to evaluate a restrictive antibiotic outpatient protocol for the treatment of mild-to-moderate episodes of AD.

Methods

All patients with symptoms of AD presenting to our emergency department were assigned a modified Neff stage. Patients with mild AD received outpatient treatment without antibiotics. Patients with mild AD and comorbidities were admitted to receive the same treatment. Patients with moderate AD were admitted for 48 h and were then managed as outpatients until they had completed 10 days of antibiotic treatment.

Results

Between April 2013 and November 2014, we attended 110 patients with a diagnosis of AD, 77 of whom we included in the study: 45 patients with mild AD and 32 with moderate AD. Of the patients with mild AD, 88.8 % successfully completed the non-antibiotic, non-admission treatment regime and 95.5 % benefited from a non-antibiotic regime, whether as outpatients or inpatients. A total of 88 % of patients with mild AD and 87.5 % of patients with moderate AD who met the inclusion criteria completed treatment as outpatients without incident. No major complications (abscess, emergency surgery) or deaths were recorded.

Conclusions

Outpatient treatment without antibiotics for patients with mild AD is safe and effective. Patients with moderate AD can be safely treated with antibiotics in a mixed regime as inpatients and outpatients.