On the methodology for measuring thickness of glomerular basement membranes

Sir, We read with interest the multicentre Italian study by Frascàet al. [1] that confirms that a proportion of patients (6/51)     

On the art of anastomotic posterior urethroplasty: a 27-year experience

PURPOSE: We determined the various operative details of anastomotic posterior urethroplasty that are essential for a successful result. MATERIALS AND METHODS: We reviewed the medical records of 155 patients who had undergone anastomotic repair of posterior urethral strictures or distraction defects between 1977 and 2003. Patient age ranged from 3 to 58 years (mean 21) and all except 1 had sustained a pelvic fracture urethral injury as the initial causative trauma. Repair was performed with a perineal procedure in 113 patients, elaborated perineal in 2 and perineo-abdominal in 40. Followup ranged from 1 to 22 years. RESULTS: The results were successful in 104 (90%) cases after perineal (including 2 elaborated perineal) and in 39 (98%) after perineo-abdominal repair. Successful results were sustained for up to 22 years after surgery. Urinary incontinence did not develop in any patients while 2 lost potency as a direct result of anastomotic surgery. CONCLUSIONS: Of the operative details 3 constitute the gold triad that assures a successful outcome, namely complete excision of scarred tissues, fixation of healthy mucosa of the 2 urethral ends and creation of a tension-free anastomosis. When the bulboprostatic urethral gap is 2.5 cm or less, restoration of urethral continuity may be accomplished with a perineal procedure after liberal mobilization of the bulbar urethra. For defects of 2.5 cm or greater the elaborated perineal or perineo-abdominal transpubic procedure should be used. In the presence of a competent bladder neck, anastomotic surgery does not result in urinary incontinence. Impotence is usually related to the original trauma and rarely (2%) to urethroplasty itself.     

State of the art 2007

The beginning of the modern hospice movement and palliative medicine relates to the recognition of the fact that a cure-oriented health care system often neglects the critically ill and the dying in terms of appropriate treatment and human care. Therefore, the idea was born to offer comprehensive medical, nursing, psychological, social and spiritual care for these patients and their families at a suitable location . This first location was St Christopher's Hospice in London; the starting point of a still ongoing humanly and ethically demanded development.     

On the prevention and analysis of missing data in randomized clinical trials: the state of the art

We summarize and elaborate on the recently published National Research Council report entitled "The Prevention and Treatment of Missing Data in Clinical Trials." We tailor our discussion to orthopaedic trials. In particular, we discuss the intent-to-treat principle, review study design and prevention ideas to minimize missing data, and present state-of-the-art sensitivity analysis methods for analyzing and reporting the results of studies with missing data.     

PCI: state of the art

The restenosis issue which has not been resolved during the history of PCI is now being solved by drug eluting stent. In RAVEL trial which is a randomized control trial addressed to simple lesion, the restenosis rate was 0%. In SIRIUS trial addressed to more real world lesions, the restenosis rate was higher (8.9%) than expectation, especially the proximal margin restenosis was high (5.8%). The new trials preventing the edge injury at the deployment could reduce the edge restenosis rate to 2.1%. Because of the drastic decrease of restenosis rate, the indication of PCI is spreading to the lesions whose main problem is the restenosis before the DES era. They are diffuse diseases, small vessel diseases, bifurcation lesions, chronic total occlusions, instent restenosises and left main diseases in which superiority of DES for BMS is reported. Although there are no evidences so far, DES may have higher incidence of subacute and/or late stent thrombosis than BMS. Because the mortality of late stent thrombosis is high, antiplatelet therapy is considered to be continued for longer time. In Japan, because the DES was introduced before the approval of clopidogrel, it was concerned about that incidence of thrombosis would be higher than other countries. In j-Cypher trial, a observational registry trial in Japan, revealed that the subacute thrombosis rate was lower level of the other studies and safety of DES utilization with ticlopidine based antiplatelet regimen. There are no evidences that DES improves the long-term prognosis of the patients with coronary artery disease. Although in terms of the long-term prognosis in multivessel disease, PCI with BMS was comparable to CABG except for DM, ARTS II trial revealed the superior survival rate of DES at 1 year. The results of on going more real world trials are mandatory.     

The art of the successful consultation

The current trends in the patients options for making decisions to have cosmetic surgeries have made the provider-closing process more intense and complicated. These trends include, but are not limited to, increased price shopping, more comparison shopping, increased use of the internet versus word of mouth and more knowledge available in conventional media. This discussion focuses on the process that takes place in the practice after the first ringing of the phone and after having successfully gotten the word out. After the deployment of positive and result-oriented advertisements, staff consultation closure skills determine your economic success. Included are discussions of major challenges in executing successful consultations related to getting the entire practice, including the doctor, to accept and employ a wellexecuted consultation. Four essentials of the successful and artful consultation are discussed: the phone inquiry, the follow-up after the phone call, the in-person contact, and the follow-up after the in-person contact, with the ultimate goal of a continual flow of paying patients.     

Sepsis: state of the art

In recent years, we have considerably widened our knowledge of the pathophysiology of sepsis and some procedures, aiming both to relieve symptoms and control the inflammation/coagulation reaction, have proven to be effective in increasing survival. This improves when mechanical ventilation is applied with low tidal volumes, fluid replacement and the use of cardioactive drugs are titrated on the oxygen saturation of hemoglobin in the central venous system and blood glucose does not exceed certain limits. It is also evident that inflammation and coagulation are closely related to each other. The inhibition of only one pathway, such as the inhibition of inflammation with high dosage steroids or the inhibition of coagulation with antithrombin, does not produce a survival improvement. The only molecule which has proven to be notably effective in reducing mortality is Activated Protein C interacting on coagulation/fibrinolysis, as well as on inflammation processes. Multinodal modulation of several interdependent processes may be the probable reason for the proven effectiveness of this treatment.     

Epidermoid splenic cyst--state of the art

In order to understand the features of splenic epidermoid cysts and their possible associated complications, four cases of splenic epidermoid cyst are presented in this report, two in children, one of them appeared in a child affected by a EBV and BH sepsis complicated with splenic abscesses due to scratch cat disease. The other two cases were adults. According to our histophatological findings, the pathogenesis may be related to a citodiferentation from mesothelium to squamous metaplasia. Our current knowledge about the role of spleen on immunological activity, mainly against capsulated germs, and the increase risk of overwhelming postesplenectomy septicemia have contributed to our conservative attitude about splenic surgery. We believe that management during the neonatal period should be conservative because cysts tend to disappear in most cases. In older children with a small cyst our recommendation is punction-aspiration and sclerotherapy, with ultrasound follow-up control.