Showing papers in "British Medical Bulletin in 2007"

Creatine kinase monitoring in sport medicine

Abstract: Areas of general agreement: Total creatine kinase (CK) levels depend on age, gender, race, muscle mass, physical activity and climatic condition. High levels of serum CK in apparently healthy subjects may be correlated with physical training status, as they depend on sarcomeric damage: strenuous exercise that damages skeletal muscle cells results in increased total serum CK. The highest postexercise serum enzyme activities are found after prolonged exercise such as ultradistance marathon running or weight-bearing exercises and downhill running, which include eccentric muscular contractions. Total serum CK activity is markedly elevated for 24 h after the exercise bout and, when patients rest, it gradually returns to basal levels. Persistently increased serum CK levels are occasionally encountered in healthy individuals and are also markedly increased in the pre-clinical stages of muscle diseases. Areas that are controversial: Some authors, studying subjects with high levels of CK at rest, observed that, years later, subjects developed muscle weakness and suggested that early myopathy may be asymptomatic. Others demonstrated that, in most of these patients, hyperCKemia probably does not imply disease. In many instances, the diagnosis is not formulated following routine examination with the patients at rest, as symptoms become manifest only after exercise. Some authors think that strength training seems to be safe for patients with myopathy, even though the evidence for routine exercise prescription is still insufficient. Others believe that, in these conditions, intense prolonged exercise may produce negative effects, as it does not induce the physiological muscle adaptations to physical training given the continuous loss of muscle proteins. Growing points: High CK serum levels in athletes following absolute rest and without any further predisposing factors should prompt a full diagnostic workup with special regards to signs of muscle weakness or other simple signs that, in both athletes and sedentary subjects, are not always promptly evident. These signs may indicate subclinical muscle disease, which training loads may evidence through the onset of profound fatigue. It is probably safe to counsel athletes with suspected myopathy to continue to undertake physical activity at a lower intensity, so as to prevent muscle damage from high intensity exercise and allow ample recovery to favour adequate recovery.

Measuring socioeconomic position in health research

Abstract: Objective: In this article we review different measures of socioeconomic position (SEP) and their uses in health-related research. Areas of agreement: Socioeconomic circumstances influence health. Areas of controversy: Generally, poorer socioeconomic circumstances lead to poorer health. This has generated a search for generic mechanisms that could explain such a general association. However, we propose that there is a greater variation in the association between SEP and health than is generally acknowledged when specific health outcomes are investigated. We propose that studying these variations provide a better understanding of the aetiological mechanisms relating specific diseases with specific exposures. Areas to develop research: Using different indicators of SEP in health research can better capture these variations and is important when evaluating the full contribution of confounding by socioeconomic conditions. We propose that using an array of SEP indicators within a life course framework also offers considerable opportunity to explore causal pathways in disease aetiology.

Mental health in low- and middle-income countries

Abstract: Mental disorders in low- and middle-income countries (LAMIC) do not attract global health policy attention. This article is based on a selective review of research on mental disorders in adults in LAMIC since 2001 and recent analyses of disease burden in developing countries. Mental disorders account for 11.1% of the total burden of disease in LAMIC. Unipolar depressive disorder is the single leading neuropsychiatric cause of disease burden. Alcohol use disorders account for nearly 4% of the attributable disease burden in LAMIC. Mental disorders are closely associated with other public health concerns such as maternal and child health and HIV/AIDS. Poverty, low education, social exclusion, gender disadvantage, conflict and disasters are the major social determinants of mental disorders. Clinical trials demonstrate that locally available, affordable interventions in community and primary care settings are effective for the management of mental disorders. Mental health resources are very scarce and investment in mental health is < 1% of the health budget in many countries. The majority of people with mental disorders do not receive evidence-based care, leading to chronicity, suffering and increased costs of care. Strengthening care and services for people with mental disorders is a priority; this will need additional investment in human resources and piggy backing on existing public health programmes. Campaigns to increase mental health literacy are needed at all levels of the health system.

Magnetic resonance imaging versus arthroscopy in the diagnosis of knee pathology, concentrating on meniscal lesions and ACL tears: a systematic review.

Abstract: Purpose: Magnetic resonance imaging (MRI) is of great aid in the diagnosis of knee lesions. Most diagnostic studies comparing MRI and arthroscopy have shown good diagnostic performance in detecting lesions of the menisci and cruciate ligaments. Nevertheless, arthroscopy has remained the reference standard for the diagnosis of internal derangements of the knee, against which alternative diagnostic modalities should be compared. Methods: We took arthroscopy to be the ‘gold standard’, and we undertook a systematic review of MRI and arthroscopy in the diagnosis of internal derangements of the knee. We used Coleman scoring methodology to identify scientifically sound articles in a reproducible format. Results: MRI is highly accurate in diagnosing meniscal and anterior cruciate ligament (ACL) tears. It is the most appropriate screening tool before therapeutic arthroscopy. It is preferable to diagnostic arthroscopy in most patients because it avoids the surgical risks of arthroscopy. The results of MRI differ for medial and lateral meniscus and ACL, with only 85% accuracy.

Shock wave therapy for chronic plantar fasciopathy.

Abstract: Introduction: Relevant data of randomized-controlled studies on shock wave treatment for chronic plantar fasciopathy are statistically and clinically heterogeneous. Methods: Randomized trials were identified form a current search of the Cochrane Bone, Joint and Muscle Trauma Group specialized register of trials, the Cochrane Central Register of Controlled Trials, MEDLINE and reference lists of articles and dissertations. We identified and retrieved a total of 17 articles. Methodological quality criterial included appropriate randomization, allocation concealment, blinding, number lost of follow-up and intention to treat analysis. Significant heterogeneity between studies precluded pooled analyses. Instead, individual trial results were described in the text. Results: We identified conflicting results in the 17 studies, involving more than 2100 participants. There was considerable heterogeneity in terms of methodological quality, treatment regimen, patient selection and follow-up period. Conclusions: With current studies heterogenous in terms of the duration of the disorder; type, frequency and total dose of shock wave therapy (SWT); period of time between SWT; type of management and control group; timing of follow-up and outcomes assessed, a pooled meta-analysis of SWT for chronic plantar fasciopathy was considered inappropriate. Neverhteless, there was a preponderance of well-designed studies showing favourable results. It appears that one should only consider SWT for plantar fasciopathy after more common, accepted and proven non-invasive treatments have failed.

Investigating emotion in moral cognition: a review of evidence from functional neuroimaging and neuropsychology

Abstract: Introduction: Human moral decision-making has long been a topic of philosophical debate, and, more recently, a topic for empirical investigation. Central to this investigation is the extent to which emotional processes underlie our decisions about moral right and wrong. Neuroscience offers a unique perspective on this question by addressing whether brain regions associated with emotional processing are involved in moral cognition. Method: We conduct a narrative review of neuroscientific studies focused on the role of emotion in morality. Specifically, we describe evidence implicating the ventromedial prefrontal cortex (VMPC), a brain region known to be important for emotional processing. Results: Functional imaging studies demonstrate VMPC activation during tasks probing moral cognition. Studies of clinical populations, including patients with VMPC damage, reveal an association between impairments in emotional processing and impairments in moral judgement and behaviour. Conclusions: Considered together, these studies indicate that not only are emotions engaged during moral cognition, but that emotions, particularly those mediated by VMPC, are in fact critical for human morality.

Hyperthermia induced by microwave diathermy in the management of muscle and tendon injuries.

Abstract: Introduction: Hyperthermia induced by microwave diathermy raises the temperature of deep tissues from 418 Ct o 458C using electromagnetic power. Microwave diathermy is used in the management of superficial tumours with conventional radiotherapy and chemotherapy and, recently, its use has been successfully extended to physical medicine and sports traumatology in Central and Southern Europe. Methods: We searched the literature for relevant studies. Most of the published studies in these fields have used 434 and 915 microwave diathermy, as these wavelengths are most effective. Results: Hyperthermia induced by microwave diathermy into tissue can stimulate repair processes, increase drug activity, allow more efficient relief from pain, help in the removal of toxic wastes, increase tendon extensibility and reduce muscle and joint stiffness. Moreover, hyperthermia induces hyperaemia, improves local tissue drainage, increases metabolic rate and induces alterations in the cell membrane. Conclusions: The biological mechanism that regulates the relationship between the thermal dose and the healing process of soft tissues with low or high water content or with low or high blood perfusion is still under study. Microwave diathermy treatment at 434 and 915 MHz can be effective in the short-term management of musculo-skeletal injuries.

Current and potential therapeutic strategies for the treatment of ataxia-telangiectasia

Abstract: Ataxia-telangiectasia (A-T) is a rare autosomal recessive genetic disorder characterized by progressive neurodegeneration, a high risk of cancer and immunodeficiency. These patients are also hypersensitive to radiotherapy. The gene product defective in this syndrome, ATM (ataxia-telangiectasia mutated), normally recognizes DNA damage and signal to the DNA repair machinery and the cell cycle checkpoints to minimize the risk of genetic damage. No curative strategy for this disease exists. Treatment has focused on slowing the progress of the neurodegeneration; devising approaches for the treatment of tumours while minimizing side effects and treatment with immunoglobulin for the immunodeficiency. The most debilitating feature of this disorder is the progressive neurodegeneration due to loss of Purkinje cells in the cerebellum and malfunction of other neuronal cells. Correcting for the loss of Purkinje cells is technically very difficult and would require transplantation of embryonic stem cells. However, since it seems likely that oxidative stress may contribute to the neurodegeneration in A-T, potential therapies based on the use of antioxidants offer some hope. We describe the natural course of disease, some supportive therapeutic approaches already in use and those with potential based on our knowledge of molecular and cellular characteristics of this disorder.

Modern concept of vascular cognitive impairment

Abstract: Background Vascular cognitive impairment (VCI) has superseded vascular dementia and multi-infarct dementia as the concept to be used in cognitive decline due to cerebrovascular disease. Method The literature was reviewed with regard to the concept of VCI and its incidence, pathophysiological substrate, clinical features and management. Results A change in the diagnostic paradigm from the current Alzheimer-based definition of vascular dementia to VCI will allow the earlier identification of cases and will identify a different population from that recognized using the current criteria for vascular dementia. Conclusions Case identification at the earliest possible stage affords the greatest opportunity for treatment that may slow the rate of progression.

Adverse drug events in the elderly.

Abstract: Background: Increasing recognition of the burden associated with iatrogenic disease has led to international interest into how best to promote patient safety. Within this field, the subject of adverse drug events (ADEs) has received particular attention, this reflecting the known high frequency with which such events occur, particularly in the elderly. Methods: We conducted a narrative review summarizing epidemiological data on medication-related adverse events in elderly people, considering various known causes of such events and suggesting practical ways in which prescribing can be made safer for high-risk populations. Results: There is an increasing recognition that a relatively high proportion of ADEs in the elderly may be preventable. Systems issues have been found to play a particularly powerful role in this context, resulting in several promising approaches to address the problem. Conclusions: Relatively simple system changes have the potential to reduce the burden associated with medication-related adverse events in the elderly.

Early rheumatoid arthritis.

Abstract: Background This review outlines current knowledge of diagnosis, assessment, treatment and risk factors for early rheumatoid arthritis (RA). Methods Selective review of current literature was obtained by searching the terms 'rheumatoid arthritis' and 'early'. Results Three issues dominate the current views on early RA. First, its recognition may be difficult. Many experts consider that early inflammatory arthritis should only be classified as RA after several months' of observation. Secondly, there is emphasis on early intensive treatment with conventional disease-modifying drugs or biologics, especially tumour necrosis factor inhibitors. Thirdly, there is a debate on the risk factors with evidence of genetic risks and environmental factors like smoking that may trigger RA. Developing citrullinated proteins followed by anti-cyclic citrullinated peptide antibodies, specific for RA, appears to be a crucial pathogenetic step. Discussion Early RA needs immediate specialist assessment and review. Early intensive therapy is effective but needs to be focussed on patients mostly at risk of severe progressive disease.

Repetitive shock wave therapy for lateral elbow tendinopathy (tennis elbow): a systematic and qualitative analysis

Abstract: Objective: Pooled meta-analyses of statistically and clinically heterogeneous data of randomised-controlled studies are difficult to interpret. Therefore, a qualitative study-by-study assessment was thought to be of greater relevance, to physicians confronted with a therapy-resistant tennis elbow patient, to determine the effectiveness of shock wave therapy (SWT) for lateral elbow tendinopathy. Setting: Orthopaedic clinic. Methods: Randomized trials were identified from a current search of The Cochrane Bone, Joint and Muscle Trauma Group specialized register of trials, the Cochrane Central Register of Controlled Trials, MEDLINE and reference lists of articles and dissertations. We included 10 trials that randomized 948 participants to SWT or placebo or treatment control. For each trial, two independent reviewers assessed the methodological quality and extracted data. Methodological quality criteria included appropriate randomization, allocation concealment, blinding, number lost to follow-up and intention-to-treat analysis. Results: Conflicting results of the 10 studies were found. There was considerable heterogeneity in terms of methodological quality; treatment regimen; patient selection and follow-up period, precluding pooled analyses. Instead, individual trial results were described in the text. Only six trials had a high-quality methodology. Two independent high-quality randomized placebo-controlled trials (196 participants) reported significant success of SWT over placebo (65 versus 28%; 61 versus 29%). Design of both trials included enrolment of chronic recalcitrant patients only; 1500‐2000 shocks of low-energy flux density (0.1 mJ/mm 2 ) applied to the site of maximal discomfort (clinical focusing) in weekly intervals; no use of local anaesthesia and main follow-up at least 3 months after the last application. Three other independent high-quality trials (406 participants) did not find any benefit of SWT over placebo (32 versus 33%; 35 versus 34%; 39 versus 31%). In these three trials, study designs deviated from the design described earlier, enrolling acute patients or applying SWT under

Trachoma: an overview.

Abstract: Trachoma is the most common infectious cause of blindness worldwide. It afflicts some of the poorest regions of the globe, predominantly in Africa and Asia. The disease is initiated in early childhood by repeated infection of the ocular surface by Chlamydia trachomatis. This triggers recurrent chronic inflammatory episodes, leading to the development of conjunctival scarring. This scar tissue contracts, distorting the eyelids (entropion) causing contact between the eyelashes and the surface of the eye (trichiasis). This compromises the cornea and blinding opacification often ensues. The World Health Organization is leading a global effort to eliminate Blinding Trachoma, through the implementation of the SAFE strategy. This involves surgery for trichiasis, antibiotics for infection, facial cleanliness (hygiene promotion) and environmental improvements to reduce transmission of the organism. Where this programme has been fully implemented, it has met with some success. However, there are significant gaps in the evidence base and optimal management remains uncertain.

Diagnosing tuberculosis in HIV-infected patients: challenges and future prospects.

Abstract: Introduction: The lack of an effective diagnostic test for smear-negative tuberculosis (TB) is a major contributor to the death of HIV patients in countries with high burden of HIV/Mycobacterium tuberculosis co-infection. The problem: The prolonged incubation time of traditional culture techniques delays time to diagnosis and instigation of effective antituberculous therapy in those who are smear negative. In addition, the increased prevalence of extrapulmonary TB in HIV patients presents a particular diagnostic challenge in resource-poor settings Discussion: This review highlights the challenges of diagnosing TB in patients with HIV and the recent advances in development of commonly used and novel diagnostic tests for TB.

Acute upper gastrointestinal haemorrhage

Abstract: Acute gastrointestinal haemorrhage is a common medical emergency that has a hospital mortality of approximately 10%. Peptic ulcer bleeding, complicating non-steroidal anti-inflammatory drugs, aspirin or Helicobacter pylori infection is the most common cause of major bleeding. Gastro-oesophageal varices are less common but managing the underlying liver disease and the severity of bleeding may be demanding. The prognosis of patients presenting with acute bleeding is dictated by the presence of medical co-morbidities and by the severity of liver disease in patients with varices. Validated prognostic scoring systems, based upon the severity of bleeding, diagnosis, endoscopic findings and extent of co-morbidities, predict mortality and have clinical utility. The treatment of non-variceal bleeding is based upon cardiovascular resuscitation followed by endoscopic therapy in patients with active bleeding or major stigmata of recent haemorrhage. Proton pump inhibitor drugs reduce the risk of re-bleeding but have little effect on mortality. Emergency surgery is undertaken for uncontrolled bleeding or re-bleeding that cannot be controlled by further endoscopic therapy. Oesophageal varices are managed by fluid resuscitation, antibiotics and endoscopic band ligation. Vasoactive drugs may stop active bleeding but have no effect upon mortality. Management of the complications of the underlying liver disease and complete variceal ablation in a banding programme are essential. Gastric varices are treated by injection with tissue adhesives or transjugular intrahepatic porto-systemic shunt (TIPSS) insertion. Surgical intervention has little role in the management of varices and patients who do not respond to endoscopic therapies are best treated by TIPSS.

Detection of the sentinel lymph node in breast cancer

Abstract: Introduction: Introduction: Axillary lymph node status for lymphatic staging in breast cancer is the best prognostic indicator and guides systemic treatment. Sentinel lymph node (SLN) biopsy is a novel, minimally invasive technique for lymphatic staging proven to improve quality of life. The accurate detection of the SLN is paramount for the success of the procedure. Methods: Relevant literature was reviewed with regards to the different dyes and techniques used for the detection of SLN in breast cancer. Results: Highest identification rates and lowest false negative rates are achieved by using the combined blue dye and radiocolloid technique with pre-operative imaging using a gamma camera. There is a well-recognized learning curve to successfully perform SLN biopsy. Conclusions: The concept of SLN has been well validated and is the standard of care in early breast cancer. A multidisciplinary approach and structured training is the key to the successful introduction of the technique.

The role of NICE technology appraisal in NHS rationing

Abstract: Objective: This article examines the role of National Institute of Health and Clinical Excellence (NICE) technology appraisal in detail, focussing on the process itself and the methods used to establish cost-effective practices for the National Health Service (NHS). Areas of agreement: Approaches to identifying both effective and cost-effective practices have become central to rationing decisions in the NHS. The establishment of the NICE, which produces guidance on what treatments should be provided by the NHS, represents the most visible approach to introducing economic considerations into these decisions. Areas of controversy: The decisions over which activities will be displaced by NICE approved treatments are made at a local level, while the cost-effectiveness threshold used to evaluate technologies is set nationally. This may result in treatments being displaced which are more cost-effective than those being introduced.

Are the assumptions underlying patients choice realistic?: a review of the evidence

Abstract: Introduction: This paper presents a thematic review of the assumptions underlying patient choice in the NHS to examine who is meant to be making choices in the policy, what choices they are meant to be making and how those choices are meant to be made. Discussion: This paper suggests that policies to increase patient choice require a significant investment in terms of restructuring primary-care services to allow them to happen, as well as to present relevant information to patients, but that patients may not want to make choices about where and what type of treatment they receive for the most part, being content with having a larger say in when they are treated.

HIV and HIV treatment: effects on fats, glucose and lipids.

Abstract: BACKGROUND: Since the advent of effective antiretroviral therapy, infection with the human immunodeficiency virus has been transformed, in the Western world, to a chronic disease associated with a variety of metabolic complications. Aims This review provides a brief summary of our current understanding of the epidemiology, clinical presentation and therapeutic approaches of what is termed 'the HIV-associated lipodystrophy syndrome' and of HIV-associated lipid and glucose metabolic abnormalities. Other metabolic associations including lactic acidosis, HIV-associated bone disease and the effect of the virus on other endocrine pathways are outside the scope of this article. METHODS: A bibliographic search was performed using Entrez Pubmed, edition 2.0, by the National Library of Medicine for articles only in the English language using Boolean operators and the terms 'HIV, HAART, lipodystrophy, lipoatrophy, lipohypertrophy, hyperlipidemia, diabetes and metabolism, cost of illness'. The Program and Abstract Books of the 8th International Workshop on Adverse Drug Reactions and Lipodystrophy in HIV (September 24-26, 2006, San Francisco, USA), the 4th International AIDS Society Conference on HIV Pathogenesis (July 22-25, 2007, Sydney, Australia) and the 47th Annual Interscience Conference on Antimicrobial Agents and Chemotherapy (September 17-20, Chicago, USA) were searched for relative abstracts. Previous publications were used to identify further references. Approximately 1400 articles and abstracts were identified of which 104 were selected for review. RESULTS: Specific medications and medication classes increase the lipoatrophy and lipodystrophy risk. A change of treatment strategy might be beneficial in improving adipose tissue deposition. The effects of HIV on metabolism offer new insights into cardiovascular disease pathogenesis.

Forensic databases: benefits and ethical and social costs.

Abstract: Introduction: This article discusses ethical, legal and social issues raised by the collection, storage and use of DNA in forensic databases. Review: The largest and most inclusive forensic database in the world, the UK National DNA database (NDNAD), leads the worldwide trend towards greater inclusivity. The performance of the NDNAD, criteria for inclusion, legislative framework and plans for integrating forensic databases across Europe are discussed. Comparisons are drawn with UK biobank that has started collecting DNA samples linked to medical records and, unlike the NDNAD, requires informed consent from volunteers, allows withdrawal of samples and only includes adults. The potential uses of research into genes associated with violent and ‘antisocial’ behaviour are discussed in the context of an increasing degree of surveillance in the UK. Conclusion: It should not be assumed that the benefits of forensic databases will necessarily override the social and ethical costs, regardless of changes to the criteria for inclusion or the permitted uses of samples and profiles. The expansion of forensic databases raises issues of relevance to the medical profession.

Prostate cancer: palliative care and pain relief

Abstract: Introduction Metastatic prostate cancer is incurable and causes significant morbidity. The focus of treatment should be on improving quality of life through appropriate oncological treatment and palliative care. The National Institute for Clinical Excellence guidelines for urological cancer recommends palliative care for all patients with prostate cancer, according to need. This paper outlines the principles of modern palliative care in patients with metastatic prostate cancer within the UK. Discussion We highlight the main physical symptoms encountered in metastatic prostate cancer and their management. We also introduce the UK Department of Health's 'End-of-Life Care Programme'. This initiative intends to improve the lives and deaths of all patients with incurable disease and should be a priority for all health care professionals, within any setting. Conclusion Clearly, we have addressed the management of metastatic prostate cancer within the UK setting, though any of these government initiatives may provide a resource and framework in other countries.

The new model NHS: performance, perceptions and expectations.

Abstract: OBJECTIVE This article analyses the transformation of the National Health Service (NHS) in England from a command-and-control to a mimic market model. AREAS OF AGREEMENT Even while introducing market incentives and encouraging private providers, the new model preserves the essential characteristics of the NHS as a universal, tax-funded service free at the point of delivery. AREAS OF CONTROVERSY The spectacle of famine among plenty -- service cutbacks at a time when the level of spending on the NHS is at a rate unprecedented in its history -- raises doubts about the competence of both local managers and central policy makers. Payment by results gives providers an incentive to maximize activity so prompting questions about the future rationing of resources and the role of the medical profession therein. AREAS TO DEVELOP RESEARCH: The implementation and effects of the policies already introduced and their modification in the light of experience.

Minimally invasive hip arthroplasty: a quantitative review of the literature

Abstract: Purpose: To perform a comprehensive quantitative review of the published literature and to assess the methodology of studies comparing the surgical outcomes in minimally invasive hip arthroplasty (MIHA). Methods: We conducted a comprehensive literature search using Medline, Embase, Cochrane, CINAHL and Google Scholar. The bibliographies of papers were also examined. All relevant articles in peer-reviewed journals were retrieved except those not mentioning outcomes, case reports, review of literature and letters to editors. Two authors independently scored the quality of the studies using a modified Coleman Methodology Score with 10 criteria which allow critical analysis of the design and implementation of a particular study. The results are recorded as a final score between 0 and 100. We collected data for year of publication, type of study, patient numbers, surgical method, followup, complications and patient satisfaction. Results: Thirty-six studies met our inclusion criteria giving details of 6434 HAs, 78.5% (4031) of which were implanted using MIHA techniques. The only statistically significant outcome was a reduction in length of hospital stay (P ¼ 0.02). With no significant difference noted between the two groups with respect to operating time, blood loss, dislocation and revision rates, neurological injury and incidence of peri-operative fracture, patient selection and surgeons’ experience may have had a significant effect on outcome. For instance, studies reporting outcomes on an average patient age of 48 years had significantly different results to one reporting on patients with a mean age of over 70 years. Scores were predominantly low for quality of the studies, with patient number, follow-up time and validated outcome measures being the weakest areas. Conclusion: At present, there is still a lack of quality evidence to advocate the expansion of MIHA. The better designed studies suggest that it should even be limited further to recognized expert centres. The complication rates and learning curve may be altered by changes in training and adapting surgical techniques. We emphasize the need for meticulous design in future studies comparing the outcomes of these two procedures.

Prophylactic mastectomy: ethical issues.

Abstract: Introduction: Why in particular should prophylactic mastectomy be seen more as an ethical concern than as a strictly medical question? In this article, four main explanations will be discussed. Main points: First, a risky condition is not a disease and prevention does not improve well-being. The benefits are only statistical and make sense at the population level. Secondly, the cause of the risk is a genetic factor and some might argue about genetic 'exceptionalism'. Thirdly, there is no organ as, connected to femininity, sensuality, sexuality, adulthood and motherhood as the breast. Lastly, making tough and complex choices requires assistance from ethics. Areas of agreement: Among ethical principles, western countries often rely on autonomy. The physician has to deliver all the relevant information; based on this 'knowledge' and using their own values, patients will take a decision. Area of controversy: In 1998 in France, national recommendations set a list of criteria to fulfil, reducing autonomy. Emerging areas for developing research: It might be expected that this tough issue will be solved, thanks to the improvement of prevention and therapeutic efficacy.

Endoscopic ultrasound in cancer staging.

Abstract: Background: Endoscopic ultrasound (EUS) represents one of the most significant developments in endoscopy over the past 20 years. It allows highly detailed assessment of the gastrointestinal wall layers as well as to visualize extraluminal structures such as the mediastium and retroperitoneum. Methods: The literature was reviewed to assess the role of EUS in cancer staging. Results: EUS is an integral part of the staging of many upper gastrointestinal cancers as well as rectal and lung cancer and has been shown to be cost-effective. It can be used to confirm malignancy in suspicious lesions as well as to identify and confirm nodal or metastatic spread. It has been used to re-stage cancers following chemoradiotherapy, but results are disappointing. Future developments are discussed, which may include using EUS-guided delivery of anti-tumour agents directly into tumours.

Cardiovascular disease prevention in primary care.

Abstract: Since the publication of the National Service Framework for coronary heart disease, there has been a move towards primary disease prevention with a greater focus on an individual's absolute risk. Meta-analysis and systematic reviews of the evidence for primary prevention are incomplete and the current guidelines and policy have led to considerable confusion in clinical practice. There is an increased use of risk assessment tools but no effective method of reviewing current activity with the limited integration into the existing Quality Outcome Framework. There is an inadequate evidence for some of the risk factors used to identify individuals at risk, the risk calculators used to quantify the degree of risk and the methods of communicating risk to patients are largely unproven or completely missing. There is a need for a co-ordinated vascular disease prevention programme which can be applied at the individual and at the population level but is also amenable to evaluation.

Cardiac adaptation to training and decreased training loads in endurance athletes: a systematic review

Abstract: Introduction: Changes in echocardiographic standard measurements as a consequence of training and detraining in elite or subelite athletes have not been comprehensively studied. Methods: We identified 200 potentially relevant studies from 1966 to June 2006 and eliminated 187 studies that did not fulfil the objectives of the study. We identified 13 studies with echocardiographic assessment of heart adaptation following variation in training loads in elite or subelite endurance-trained athletes. We performed a meta-analysis by studying the changes in the left ventricular end-diastolic (LVEDD), left ventricular end-systolic (LVESD), left ventricular posterior wall (LVPW) and interventricular septum thickness (IVST) dimensions induced by training. Results: A significant positive overall effect size on echocardiographic outcomes was found following training, using the fixed effect model on LVPW, LVEDD, LVESD and IVST. LVPW and LVEDD were significantly higher following training. Conclusion: Studies reported an increase in LVEDD and LVPW, following endurance training. However, the heterogeneity of the studies and the sensitivity of echocardiography technique can be two reasons, for which the results do not allow to state unequivocally that the adaptation to endurance training of highly trained hearts stems from increments of diastolic diameter of the left ventricle and lateral wall of the left ventricle (LVPW).

Role of antibody therapy in lymphoid malignancies.

Abstract: Introduction: Over the past decade, the potential for delivering targeted therapy against malignant disease by the use of monoclonal antibodies (MoAbs) has begun to be realized. The development of human or chimeric antibodies and protein engineering to combine MoAbs with other biologically active molecules, such as radio-isotopes, toxins, chemotherapy and cytokines, has made available a new range of agents with clinical activity. Discussion: This article will review the requirements and strategies for successful MoAb therapy and the clinical experience in a range of lymphoid malignancies. On the basis of substantial experience of antibodies, such as rituximab and alemtuzumab, as single agents, there is now evidence from randomized trials that the addition of antibodies to chemotherapy improves efficacy and prolongs progression free and overall survival for patients with follicular and diffuse large B-cell lymphomas. Conclusion: The trials of the next decade will address issues such as the optimal strategies and timing for clinical use, the role of radio- and immuno-conjugates and, finally, what other potential molecules, such as those influencing cell growth and death, may be targeted.

Modern trends in interventional radiology

Abstract: Background: IR is a clinical modality that makes use of imaging guidance for the performance of minimally invasive treatment. The development of new imaging technologies and interventional devices has greatly increased the number of medical conditions that may now be treated by IR. Summary: Promising new treatments in cancer therapy, the treatment of fibroids, venous access and spine interventions as well as advances in noninvasive vascular imaging, pharmacological therapies and peripheral arterial and venous interventions are providing exciting opportunities for IR, attracting significant patient interest and promising tremendous public benefit.

Refractive surgery: what patients need to know.

Abstract: Objective Most procedures to treat refractive error are based on laser surgery, but other techniques are available. We review the relative advantages and the risk associated with the different surgical options. Areas of agreement Laser refractive surgery is now a safe and effective alternative to glasses or contact lenses. Areas of controversy Because refractive surgery is an area of rapidly developing technology, the relative benefits of the different surgical options remain uncertain. AREAS TO DEVELOP RESEARCH: Controlled trials are needed to provide better guidance as to the relative merits of the different surgical options. Better interventions are required to minimize the biological response after laser surface treatment to eliminate the need for mechanical cutting of a flap for laser in situ keratomileusis. An effective surgical treatment for presbyopia is awaited.