Treating mild hypertension—An unnecessary luxury

Summary Clinical practice should be based on the results of good clinical trials, not on the opinion of individual doctors. This is particularly true of high blood pressure, for there is no disease of hypertension, and only through clinical trials has the acceptable upper limit of blood pressure been identified. The large trials that have been performed, and in particular the MRC trial of bendrofluazide and propranolol, enable the benefits of treatment to be assessed and related to the incidence of unwanted effects of treatment. Many new drugs, which are usually very expensive, have not been subjected to large clinical trials and a balance sheet of their benefit and adverse effects cannot be drawn up. Drugs that have not be assessed in large trials must be regarded both as an unnecessary and an undesirable luxury.     

Covered stent to treat saphenous venous graft perforation—A case report

This case report shows the immediate and long‐term clinical result of percutaneous coronary intervention in a patient with total occlusion of saphenous venous graft. The case also highlights the management of venous graft perforation during percutaneous intervention using a covered stent. © 2010 Wiley‐Liss, Inc.     

Ten‐year Angiographic Result of a Large Right Coronary Artery Fistula Treated Percutaneously: Many Questions Remain Unanswered

We describe an adult patient with right coronary artery to right atrium fistula, which was treated percutaneously 10 years earlier. His coronary angiogram done presently demonstrated no residual fistula, but there was persistence of aneurysmally dilated proximal right coronary artery segment that gave rise to many unanswered questions regarding management of coronary artery fistulas. We discuss the short‐ and long‐term therapeutic dilemmas in the management of coronary artery fistula.     

Eumycotic mycetoma caused by Madurella mycetomatis successfully treated with antifungals, surgery, and topical negative pressure therapy

We report a 21-year-old farmer with a 4-year history of a nodular plaque with fistulas and induration of adjacent skin. The lesion had been treated surgically at another hospital, but recurred 2 years later.
Black, charcoal-like grains were observed draining through the fistulas. A biopsy specimen showed brown grains with filaments in an abscess surrounded by macrophages, giant cells, and lymphocytes. Culture demonstrated small white colonies of Madurella mycetomatis . The patient was treated with itraconazole for 6 months, followed by surgery. TNP was initiated in the immediate post-operative period, and copious granulation tissue was observed within 1 week. Autologous skin grafting was performed, and itraconazole was continued for an additional 3 months. Although necrosis of the graft ensued, the functional result was acceptable. The patient appeared free of disease at 18 months of follow-up.
Eumycotic mycetoma is an infectious and inflammatory process that occurs after traumatic inoculation of fungi through the skin. Surgery is the treatment of choice, but successful reconstruction may be challenging and recurrence is common. Topical negative pressure (TNP) promotes the formation of granulation tissue, which facilitates closure of deep wounds and chronic ulcers. This case illustrates that eumycotic mycetoma is difficult to treat. Whether TNP contributed to the successful outcome cannot be proven but, given the generally poor response of eumycetoma to therapy, we suggest that the role of TNP in the management of this disease merits attention.     

Thoracic metastasectomy in thyroid malignancies

Background. Relatively little evidence exists to guide the decision pathway regarding thoracic metastasectomy for thyroid malignancy.

Methods. Single-institution 10-year review.

Results. Sixteen patients had surgical treatment for intrathoracic metastatic thyroid malignancy: 12 men and 4 women, mean age 43.7 years (range 19 to 77). Histopathologic type was papillary in 6 cases, follicular in 4, Hürthle cell in 3, and medullary in 3. Indication was either “bulky” disease (8 patients) or poor response to radiotherapy (8 patients). We performed 11 sternotomies and five thoracotomies. Operative mortality was 6.25%. Operative morbidity was 6.25%. Mean survival was 39.5 months (0 to 144). Nine patients died during follow-up (mean survival of 41.2 months). Six patients survived, 4 free of disease (mean survival 70 months) and 2 with further relapse (mean survival 17 months). Five-year survival was 32.5%.

Conclusions. The cohort studied is one of the largest in the literature on the topic. Surgical treatment achieved a reasonable survival in a small subgroup of patients where radiotherapy had failed or was deemed inappropriate because of the size or location of the tumor. Further follow-up and more observations will be required for evaluating these preliminary findings.     

Prognostic Value of Direct, Continuous Ambulatory Blood Pressure Monitoring in Essential Hypertension

This study assessed the prognostic value of ambulatory vs. clinic blood pressure measurement in 688 hypertensives who had undergone pretreatment 24-hour intra-arterial ambulatory blood pressure monitoring. A total of 157 first events were recorded over a follow-up period of 9.2±4.4 years. Ambulatory systolic or diastolic blood pressure parameters (whether 24-hour mean, daytime mean, or nighttime mean) or ambulatory pulse pressure provided independent prognostic information in conjunction with clinical variables. The most predictive models contained the ambulatory systolic blood pressure parameters. Age, male gender, South Asian origin, diabetes mellitus, and previous cardiovascular disease were additional independent predictors of events. In a subgroup of 295 uncomplicated patients, 24-hour ambulatory pulse pressure was an independent predictor of left ventricular mass index and maximal carotid intima-media thickness. Baseline clinic blood pressure parameters did not provide independent information for the prediction of events or target organ damage. Therefore, in this study, ambulatory blood pressure proved to be superior to clinic measurement for cardiovascular risk stratification. However, the routine use of ambulatory blood pressure monitoring is not currently recommended, mainly because of a lack of outcome trials based on the treatment of ambulatory blood pressure levels.