When and how should we screen for hereditary hemochromatosis?

Hemochromatosis is the clinical expression of iron overload and occurs as hereditary and secondary variants. In hereditary hemochromatosis, an inborn error in iron metabolism results in excess absorption of dietary iron, which gradually accumulates in the liver, pancreas, and heart. The most common form of hereditary hemochromatosis is related to homozygosity for the C282Y mutation in the HFE gene. Early diagnosis is essential because hereditary hemochromatosis is common, severe, and treatable. Early manifestations consist of asthenia, arthralgia, and serum transferrin saturation elevation. The C282Y mutation should be looked for to confirm the diagnosis in the patient and family members. Measurement of serum transferrin saturation followed by genetic testing in individuals with values above 45% is a reasonable screening strategy.     

When should quality of life be measured after radical cystectomy?

AIM: In this prospective study our aim was to establish the time it takes cystectomized patients' to adapt to their new health status. MATERIALS AND METHOD: A total of 68 patients, having radical cystectomy for bladder cancer (64 males and 4 females) were enrolled in the study. The mean age of the group was 55.4 +/- 8.0 years (range 38-70 years). Continent urinary diversion was applied to 17 while the rest had incontinent urinary diversions. There was no statistical difference between those who had continent and incontinent diversions in regard to pre-operative stage. All patients were given a Beck's Depression Inventory (BDI), an EORTC-QLQ C-30 Version 2 (European Organization for Research on Treatment of Cancer Quality of Life Questionnaire C-30 Version 2) quality of life measurement scale pre-operatively, and post-operatively 3, 6, 12 and >12 months (every 6 months). Log-rank and Student's t-test was used for statistical analysis of the results. RESULTS: The mean follow-up of the study group was 27.7 +/- 7.3 months (range 12-46 months). Five patients at the first 3rd-month control, seven at the 6th-month control and eight at the 12th-month control did not appear for interview, but their available results were also included in the overall assessment. The mean functional score of the study group, evaluated by QLQ C-30, was 80 +/- 25.4 pre-operatively. There is dramatic decrease at the 3rd-month control (56.9 +/- 25.1; p < 0.01). The overall functional score after 12 months (80 +/- 20) is back to the pre-operative value. The mean symptom score of the group pre-operatively was 29.5 +/- 16.7, which showed similar results at 3 and 6 months post-operatively of 29.8 +/- 16.7 and 30.6 +/- 19.4, respectively (p > 0.05). At the 12th-month and thereafter the symptom scores of the patients decreased significantly in comparison to both the pre-operative and the post-operative 3-6 months (23.4 +/- 13.7 and 21.8 +/- 18.5, respectively; p < 0.01 for all). The self-rating general health status of this group was lowest pre-operatively with a mean of 49.8 +/- 26.5. Interestingly, there was a statistically significant increase in the general health status assessment of the patients even at the early post-operative period of 3 months (61.4 +/- 17.2; p < 0.01). The increase in the well-being of the patients increased linearly until the 12th-month control and stabilized thereafter. There was a 23% pre-operative depression rate, which comes down to 16% at the 12th-month control. The peak depression scores suggesting depression are observed at the 3rd-month controls. There is a gradual decrease in depression score starting from the 6th-month controls and all reach minimum scores after 12 months. Ninety-six percent of the study group showed scores even lower than the pre-operative ones. The mean pre-operative and post-operative 12th-month control scores were 11.5 +/- 7.7, and 8.1 +/- 6.8, respectively (p < 0.01). CONCLUSION: Both psychological and health-related quality of life measures come to baseline values and stabilize after the 12th-month period, suggesting that the time frame for the adaptation of patients is 12 months in patients undergoing radical cystectomy surgery. Therefore, we believe it is better to perform any quality of life assessment as an end-point criterion for comparison of treatment modalities in radical cystectomy patients after 12 months.     

When should radiotherapy be used after radical prostatectomy? The RADICALS-RT Trial

Despite two recent trials of the role of early radiotherapy following radical prostatectomy, there remains no consensus as to best practice and clinicians tend to base their decisions around MDT discussion and pathological risk factors. This paper develops the argument for international Intergroup trial, RADICALS-RT, which is now recruiting, and which is our opportunity to resolve this important issue.     

Lumbar discography: should we use prophylactic antibiotics? A study of 435 consecutive discograms and a systematic review of the literature

BACKGROUND: Lumbar discography can be used in the diagnostic work-up of degenerative spine disease. The most serious complication is discitis, believed to be due to penetration of the disc by a needle contaminated with skin flora. The use of prophylactic antibiotics has been advocated, although there is great concern regarding their efficacy and possible adverse effects on disc cells. METHODS: In the current study, the incidence of postdiscography discitis without the use of prophylactic antibiotics was studied in a consecutive patient group. Additionally, a systematic literature review was performed using strict criteria: 1). Discography was performed by means of a two-needle technique, 2). complications such as discitis were specifically looked for at follow-up, and 3). the exact numbers of patients and those lost to follow-up were reported. RESULTS: The clinical results of 200 patients with 100% follow-up for a minimum period of 3 months showed no case of discitis. In the literature review, 10 studies were selected. Nine studies without prophylactic antibiotics reported an overall incidence of 12 cases in 4891 patients (0.25%) or 12770 discs (0.094%). The only study with prophylactic antibiotics (127 patients) showed no case of discitis. CONCLUSIONS: Regarding the small number of patients in the only study in which antibiotics were used and the overall low incidence of postdiscography discitis, not enough evidence was found that prophylactic antibiotics can prevent discitis. It was concluded that in lumbar discography by means of a two-needle technique without prophylactic antibiotics, the risk of postdiscography discitis is minimal and there is not enough support from the literature to justify the routine use of prophylactic antibiotics.     

How should the results of a scientific study be presented? I. The oral presentation

The results of a research study can be presented through oral communications, posters, conferences and publications, etc. The present article suggests ways in which oral communications and posters can be presented. The sequence of steps leading up to an oral presentation can be divided into writing a summary, designing the graphic material, giving the presentation and defending the results. Posters have a similar structure but this format allows complex experiments to be clearly presented and a variety of illustrations to be introduced, without the strict time constraints that apply to oral presentations. Whichever format is followed, we recommend that authors answer the following questions: what was the question studied and why?, how was it studied?, what were the results?, and what do they mean? These questions help to structure the presentation effectively.     

Coarctation of the aorta and ventricular septal defect: should we perform a single-stage repair?

BACKGROUND: Optimal management for coarctation of the aorta and ventricular septal defect remains controversial. The current study was undertaken to determine outcome, including recoarctation after 2-stage repair, at our institution. METHODS: Between 1984 and 1998, 79 patients younger than 3 months with coarctation and ventricular septal defect underwent 2-stage repair at our institution. The first-stage operation consisted of subclavian flap angioplasty and pulmonary banding. The median age at the time of first operation was 28 days (range, 4-90 days), and median weight was 3.2 kg (range, 1.2-5.1 kg). Hypoplastic aortic arch was present in 27 patients, and coexisting anomalies were present in 13 patients. After a mean interval of 10.4 +/- 9.6 months, they underwent a second-stage repair, with closure of the ventricular septal defect and pulmonary debanding. RESULTS: There were 2 hospital deaths and 4 late deaths. Mean follow-up was 9.2 +/- 4.9 years (range, 2.0-18.3 years), and actuarial survival was 92.3% at 10 years (95% confidence interval, 86.6%-98.3%). Age at first operation, body weight, hypoplastic arch, and coexisting anomalies had no significant influence on overall mortality. Freedom from recoarctation rate was 90.4% at 10 years (95% confidence interval, 83.7%-97.2%). CONCLUSION: To diminish mortality and the recoarctation rate and also to decrease the possibility of complications related to circulatory arrest and allogeneic blood transfusion, 2-stage repair is still an effective technique for coarctation of the aorta associated with ventricular septal defect.     

When should we discontinue antiarrhythmic therapy for atrial fibrillation after coronary artery bypass grafting? A prospective randomized study

BACKGROUND: New-onset atrial fibrillation after coronary artery bypass grafting is common. Medical therapy includes various antiarrhythmic drugs to control heart rate and restore sinus rhythm. The purpose of this study was to determine the duration of antiarrhythmic therapy after discharge from the hospital. METHODS: One hundred twenty-nine patients in whom new atrial fibrillation after coronary artery bypass grafting developed and successfully reverted to sinus rhythm were prospectively randomized at dismissal to receive antiarrhythmic therapy for 1 week (group A; n = 44), 3 weeks (group B; n = 42), or 6 weeks (group C; n = 43). Patients were followed up for an additional 4 weeks after discontinuation of antiarrhythmic therapy for detection of recurrent atrial fibrillation. RESULTS: The incidence of new atrial fibrillation during the study period was 21.2% (256/1206). Among the 129 patients who consented to the study, conversion to sinus rhythm was accomplished with the following medications: amiodarone (group A, 82%; group B, 93%; group C, 88%; P = .29), digoxin (group A, 16%; group B, 7%; group C, 7%; P = .29), beta-blockers (group A, 27%; group B, 19%; group C, 14%; P = .30), calcium channel blockers (group A, 2%; group B, 2%; group C, 0%; P = .60), quinidine (group A, 2%; group B, 2%; group C, 7%; P = .44), and procainamide (group A, 4.5%; group B, 2%; group C, 0%; P = .37). Follow-up was completed in 128 patients (99.2%). There was no significant difference in the recurrence of atrial fibrillation among groups (0%, 2%, and 0% for groups A, B, and C, respectively). CONCLUSIONS: Patients with new atrial fibrillation after coronary artery bypass grafting, converted to normal sinus rhythm before hospital discharge, have a benign course. Antiarrhythmic therapy as short as 1 week may be appropriate in these patients.     

Incidental carcinoma of the prostate: can we and should we recommend radical prostatectomy?

INTRODUCTION: There is controversy regarding tumor control of incidental prostate cancer (PC). We evaluated in a large cohort if we can recommend radical prostatectomy after TURP. MATERIAL AND METHOD: In 52 (4.3%) from a total of 1207 patients undergoing radical prostatectomy the diagnosis had been made by TURP. In a retrospective analysis we evaluated morbidity, histopathological results, and tumor control of pT1a/b tumors. RESULTS: The number of incidentally detected PC decreased with time. In 5.8% in the TURP group and in 0.5% of the needle biopsy group, there was no residual tumor found (p<0.001). Morbidity was similar +/- TURP with the exception of operation time (206 vs 188 min) and catheter duration (19.3 vs 17.3 days). Postoperative continence was identical. There was no difference in tumor control for local recurrence-free survival and PSA-free survival with and without TURP. CONCLUSIONS: The rate of incidentally detected PC by TURP decreases over time, but in almost all cases we found clinically relevant cancer. TURP is not an adverse prognostic factor and morbidity is similar compared with patients who were diagnosed by needle biopsy. Our data confirm that we should recommend radical prostatectomy to patients who are candidates for further curative therapy.