Prenatal ultrasound and fetal MRI: the comparative value of each modality in prenatal diagnosis

Fetal MRI is used with increasing frequency as an adjunct to ultrasound (US) in prenatal diagnosis. In this review, we discuss the relative value of both prenatal US and MRI in evaluating fetal and extra-fetal structures for a variety of clinical indications. Advantages and disadvantages of each imaging modality are addressed. In summary, MRI has advantages in demonstrating pathology of the brain, lungs, complex syndromes, and conditions associated with reduction of amniotic fluid. At present, US is the imaging method of choice during the first trimester, and in the diagnosis of cardiovascular abnormalities, as well as for screening. In some conditions, such as late gestational age, increased maternal body mass index, skeletal dysplasia, and metabolic disease, neither imaging method may provide sufficient diagnostic information.     

Losartan in patients with type 2 diabetes and proteinuria: observations from the RENAAL Study

BACKGROUND: Recently, the Reduction of Endpoints in NIDDM with the Angiotensin II Antagonist Losartan (RENAAL) Study demonstrated the benefit of losartan in reducing renal outcomes in patients with type 2 diabetes and proteinuria. Additional questions concerning the reduction of proteinuria and its relationship to end-stage renal disease (ESRD) as well as cardio-renal outcomes and the safety and tolerability of losartan remain to be addressed. METHODS: Three analyses were performed: (a) the impact of losartan on the relationship between the reduction of proteinuria and ESRD; (b) a time-to-event analysis of the cardio-renal composite endpoint of ESRD, myocardial infarction, stroke or all-cause death; and (c) additional analyses of adverse events, particularly in patients with serum creatinine >or=2.0 mg/dL. RESULTS: After adjusting the values for proteinuria over the entire study, the reduction of proteinuria accounted for approximately half of the treatment effect of losartan on the risk reduction for ESRD. In addition, losartan was associated with a 21% risk reduction for the composite cardio-renal outcome (P=0.003). The addition of losartan to a conventional antihypertensive regimen did not increase the overall incidence of adverse events, regardless of severity of renal impairment. CONCLUSIONS: Losartan significantly reduced the risk of cardiorenal outcomes and was well tolerated by patients, including those with serum creatinine levels >or=2.0 g/dL. In addition, although this study shows that the reduction of proteinuria does not completely explain the impact of intervention on outcomes such as ESRD, reduction of proteinuria must remain an important consideration when treating patients with type 2 diabetes and nephropathy. However, the reduction of outcomes such as ESRD should remain the goal of therapy when evaluating renal protection in this patient population.     

Renal and cardiovascular protection in type 2 diabetes mellitus: angiotensin II receptor blockers

Aggressive treatment of hypertension is effective in reducing both microvascular and macrovascular complications in type 2 diabetes, and target BP less than 130/85 or 130/80 mmHg are now recommended. Inhibition of renin angiotensin aldosterone system (RAAS) plays an essential role in the treatment of hypertension and diabetes-related complications. Studies focusing on renal end-points suggest that angiotensin-converting enzyme inhibitors (ACE-I) are more effective than other traditional agents in reducing the onset of clinical proteinuria in both type 1 and type 2 diabetic patients with incipient nephropathy, mainly in normotensive ones (secondary prevention). However, several small trials in type 2 diabetic patients with overt nephropathy (tertiary prevention) failed to demonstrate a specific renoprotective role for ACE-I, at variance with type 1 diabetes. Three recent large trials address the question of whether angiotensin II receptor blockers (ARB) prevent the development of clinical proteinuria or delay the progression of nephropathy in type 2 diabetes. The IRMA study showed that irbesartan is more effective than conventional therapy in preventing the development of clinical proteinuria and in favoring the regression to normoalbuminuria for comparable BP control in patients with incipient nephropathy. The IDNT and RENAAL trials showed that ARB are more effective than traditional antihypertensive therapies in reducing progression toward end-stage renal failure (ESRF) in type 2 diabetic patients with overt nephropathy independently of changes in BP. Moreover, a reduction in hospitalizations for heart failure was demonstrated for ARB-treated patients compared with placebo. Furthermore, the LIFE study showed that losartan is more effective than conventional therapy in reducing cardiovascular morbidity and mortality in a cohort of diabetic patients with hypertension and left ventricular hypertrophy. In conclusion, ARB seem to be effective in both preventing renal damage and reducing progression toward ESRF in type 2 diabetic patients. Thus, the guidelines for the prevention and treatment of diabetic nephropathy are now changed. In type 1 diabetes ACE-I are the first-choice drug; in type 2 diabetes, ARB are considered first-choice drugs in secondary prevention as well as ACE-I and have been now elected the unique first-choice drug in tertiary prevention of ESRF. Finally, ARB should be considered as the first-choice drug in cardiovascular prevention too, as well as ACE-I.     

Eponymous terms in daily practice: a survey among Dutch orthopedic surgeons

Introduction

With a survey among Dutch orthopedic surgeons, we try to assess whether eponymous terms are still in use in daily practice. We also tried to find out whether younger generations tend to use them less than our older colleagues.

Materials and methods

In a survey consisting of 57 eponymous terms, 67 participants were asked to mark the eponyms they knew and whether they used them in daily practice.

Results

No correlation was observed in known/used eponyms or years of experience in 58 completed surveys. Respondents who classified themselves as trauma or general orthopedic surgeons knew or used a significantly higher number of eponyms in daily practice than orthopedic surgeons who classified themselves as spine, upper limb, lower limb, sports or pediatric surgeons.

Discussion

Eponymous terms are used frequently in daily practice. Super-specialization might eradicate the general orthopedic surgeon, and the number of eponyms known and used might become smaller and more focused on the super-specialty.

Conclusion

Our survey showed that eponymous terms are still used frequently in daily practice among both young and more senior orthopedic surgeons in The Netherlands.

     

Colorectal cancer in patients under the age of 40 years: experience from a tertiary care centre in the Czech Republic

Introduction: Colorectal cancer (CRC) in young patients is not an uncommon disease. Reports on its behaviour in young patients are conflicting. The aim of this study was to investigate patient and tumour characteristics, treatment and prognosis of this disease.

Methods: Our study group comprised all patients under the age of 40 years treated with CRC at the Department of Surgery at Motol University Hospital in Prague between the years 2005 and 2015.

Results: Thirty-eight patients under 40 years of age diagnosed with CRC were included in the study. Five patients had Lynch syndrome and six had first-degree relatives with CRC. There were 22 rectal tumours. All but four patients underwent resection of the primary tumour, all patients received chemotherapy and 13 patients received biological therapy. Disease recurrence occurred in 25.8%. Five-year survival was 47.9%. Advanced disease and adverse histological subtypes were identified as poor prognostic factors.

Conclusions: Colorectal cancer in young patients has a high incidence of predisposing conditions, aggressive histological features and advanced disease. Young patients are of a good state of health and thus should receive aggressive therapy. Clinicians should pay more attention to symptoms of CRC in young patients to be able to initiate early treatment.     

Nd:YAG laser clinical assisted in class II furcation treatment

The Nd:YAG laser efficacy associated with conventional treatment for bacterial reduction has been investigated throughout literature. The purpose of this study was to evaluate the bacterial reduction after Nd:YAG laser irradiation associated with scaling and root planning in class II furcation defects in patients with chronic periodontitis. Thirty-four furcation lesions were selected from 17 subjects. The control group received conventional treatment, and the experimental group received the same treatment followed by Nd:YAG laser irradiation (100 mJ/pulse; 15 Hz; 1.5 W, 60 s, 141.5 J/cm²). Both treatments resulted in improvements of most clinical parameters. A significant reduction of colony forming unit (CFU) of total bacteria number was observed in both groups. The highest reduction was noted in the experimental group immediately after the treatment. The number of dark pigmented bacteria and the percentage of patients with Porphyromonas gingivalis, Prevotella intermedia, and Actinobacillus actinomycetemcomitans reduced immediately after the treatment and returned to values close to the initial ones 6 weeks after the baseline for both groups. The Nd:YAG laser associated with conventional treatment promoted significant bacterial reduction in class II furcation immediately after irradiation, although this reduction was not observed 6 weeks after the baseline.     

Intrajoint comparisons of gene expression patterns in human osteoarthritis suggest a change in chondrocyte phenotype.

Osteoarthritis (OA) is a degenerative cartilage disease with varying degrees of severity within a given joint. The purpose of this study was to define a sampling procedure for comparing human minimal and advanced OA cartilage in the same patient and to determine basic patterns of gene expression in these regions. A specific hypothesis under study was that the expression level of Bcl-2 would correlate with Sox9 and aggrecan mRNA expression in vivo as has been demonstrated in vitro. Femoral condylar advanced OA cartilage was located within 1cm of overt lesions, and minimal cartilage was taken from areas with no obvious surface defects. Histological sections were scored for disease severity and chondroitin sulfate and hydroxyproline content was determined. The expression level of nine specific genes (aggrecan, collagen type II, Bcl-2, Sox9, Link protein, osteopontin, and MMP-13, -3, and -9) was determined by quantitative real time PCR. The scores for fibrillation, chondrocyte cloning, and proteoglycan depletion were significantly different between advanced and minimal OA cartilage. The advanced OA cartilage had significantly less chondroitin sulfate than the minimal OA cartilage. Osteopontin mRNA expression showed a 3.6-fold increase in advanced compared to minimal OA cartilage. In contrast, the level of mRNA coding for aggrecan, link protein, Bcl-2, Sox9 and MMP-3, -9, -13 were all decreased in advanced compared to minimal cartilage in the majority of the patients studied. Collagen type II mRNA expression displayed a wide-range of variation. A statistically significant correlation was observed both between Bcl-2 and Sox9 mRNA level, and between Bcl-2 and aggrecan mRNA expression. The patient matched comparison of minimal and advanced OA cartilage revealed differences in cellular and tissue characteristics, and changes in gene expression that may be involved in OA progression. In addition, Bcl-2 may also play a role in regulating the expression of aggrecan through Sox9 in vivo as well as in vitro.     

Initiation and Maintenance of Weight Loss after Laparoscopic Adjustable Gastric Banding. The role of Outcome Expectation and Satisfaction with the Psychosocial Outcome

Background  A premise of this study was that different psychological processes would predict the initiation and maintenance of weight loss after surgery for morbid obesity. Our aim was to examine whether more favorable preoperative expectations of psychosocial outcomes predict weight loss in the first year after laparoscopic adjustable gastric banding (LAGB) and whether postoperative satisfaction with these outcomes predicts weight maintenance in the second year after the operation. Methods  Six months before and 1 year after surgery, the “Obesity Psychosocial State Questionnaire” was filled out by 91 patients (77 female, 14 male, mean age 45 ± 9 years, mean preoperative body mass index 47 ± 6 kg/m²). We evaluated the preoperative outcome expectations and the postoperative satisfaction for the seven domains of psychosocial and physical functioning of this questionnaire, as well as the correlations between these scores and both weight loss and weight maintenance. Results  Patients showed high satisfaction with psychosocial outcomes after LAGB in all seven domains (p < 0.001), even though the improvement was less than expected in five of the domains (p ≤ 0.01). While weight loss 1 year after the operation was related to satisfaction with psychosocial outcomes (p ≤ 0.05), preoperative expectations were not related to weight loss in the first year after surgery, and satisfaction with the outcomes was not related to weight maintenance in the second year after surgery. Conclusion  Our study suggests that surgically induced effects of weight loss and weight maintenance are achieved independently of the patient’s preoperative expectations of and postoperative satisfaction with the psychosocial outcomes.