Sirs, Whilst the study by Cameron et al.1 of long-term re-infection rates of Helicobacter pylori in England is interesting, I believe it has a number of noteworthy limitations. First, the authors make no mention in their paper of whether their cohort's primary H. pylori infection was diagnosed by their general practitioner or gastroenterologist. This is an important distinction given the well-documented lack of awareness among most general practitioners of the limitations of available tests for this organism.2 More importantly, the authors do not state the proportion of their patients whose primary H. pylori infection was diagnosed serologically, a method with an inadequate positive predictive value (with high false-positive rates) when employed using commercially available kits in low prevalence populations such as that of England.3–6 If, as the authors' other recent study suggests,7 the majority of the patients included in the present study had their primary H. pylori infection diagnosed serologically by their general practitioner, one can only conclude that their estimate of the recurrence rate of this infection is flawed. Nor do the authors state the percentage of their patients who were tested for H. pylori re-infection having recently taken proton pump inhibitors, which have previously been shown to result in false-negative urea breath tests in up to 40% of patients.8 The second shortcoming of this study is the omission of a sound survival (Kaplan–Meier) analysis of the data including censoring of those lost to follow-up as a result of death, etc. The actual follow-up time of patients (as opposed to the one derived from intervals between consecutive tests) included in the study was not stated, leaving some readers with the erroneous impression that all those with no documented evidence of re-infection were in fact followed up and remained available for testing after their last negative test. Thirdly, it is rather unusual that none of the patients in the study appear to have had either their primary infection or recurrence diagnosed using the rapid urease test of gastric biopsies. This suggests that a significant proportion of patients with potentially more severe disease were excluded from this study. In addition, it is ironic that, in the face of what many would regard as an excessive degree of investigation for recurrence of this infection (an average of four tests per patient), 38.5% of those with a proven recurrence did not have any symptoms at all. Furthermore, of those who did, the majority (62.5%) were apparently tested for re-infection for reasons unrelated to their symptoms. I believe that the authors' claim, that H. pylori re-infection in England is rare following successful eradication, remains unproved.
The study aimed to investigate the safety of including patients ≥ 80 years of age at the start of a video-assisted thoracic surgery major pulmonary resection (VMPR) programme.Patients were considered for VMPR if the computed tomography/positron emission tomography (CT/PET) was suggestive of T1-3, N0-1 and M0 lesion. Age was not a criterion for exclusion at the very start of the programme. Data were collected prospectively and comparison made between two groups, (A) <80 years of age and (B) ≥ 80 years, in terms of preoperative risk factors, oncological and functional data, operative results, postoperative complications and survival.Between April 2005 and January 2011, 200 consecutive patients were considered for VMPR. A total of 160 had non-small-cell lung cancer, of whom 136 were in group A, with a median age of 66.5 (range: 42.8-79.4 years) and 24 in group B with a median age of 82 (range: 80-85.5 years). In group B, 13 were men and 11 were women. Rate of conversion to thoracotomy was similar (3 (12.5%) in group B vs 17 (12.5%) in group A, p = 0.65), and so was the mean hospital stay (5.8 ± 3.3 days in group B vs 5.9 ± 4.6 days in group A, p = 0.899). Admission to intensive care unit and atrial fibrillation were significantly higher in octogenarians (six (25%) and six (25%) in group B vs eight (5.9%) and nine (6.6%) in group A, p = 0.008 and p = 0.012, respectively). There was significantly less mean days of air leak in octogenarians (0.06 ± 0.3 days in group B vs 2.8 ± 5.6 days in group A, p = 0.000). Otherwise, there were no age-related differences in relation to morbidity, mortality and the 3-year survival rate.Octogenarians undergoing VMPR have a higher incidence of atrial fibrillation and admission to the intensive care unit for cardiopulmonary support but otherwise are no different from younger age groups when it comes to rate of conversion to thoracotomy, hospital stay, morbidity and mortality. Age should not be an excuse to deny the elderly curative VATS resection. In our experience, accepting octogenarians early in the VMPR programme did not compromise the outcome results.
Disappearing bone disease is a rare condition and usually affects young adults. Its aetiology is not known. A case of a 12-year-old female child, who had a fall and sustained a fracture mid shaft of femur and supracondylar region, is reported. On follow-up subsequent X-ray showed extensive osteolysis which was progressively affecting the other side of the pelvic girdle and femur. She was put on trial of calcitonin 50 IU by nasal spray for six months but there was no improvement. However, during the past three and half years the disease process had progressively extended to the other side of pelvic girdle and femur with fatal outcome. To the knowledge of the authors such progression in a short time has not been reported in any case so far.
The Video Assisted Thoracic Surgery (VATS) was introduced in Brazil in 1992 by Losso, Ghefter and Imaeda. Since its advent up to November 1994, 488 patients have been submitted to 497 VATS procedures in four Medical Centers of São Paulo city. The indications for the procedures were: lung diseases in 244 patients (50%), pleural disease in 155 patients (31.7%), thoracic traumas in 42 patients (8.6%), mediastinal diseases in 35 patients (7.1%), cardiovascular diseases in 7 patients (1.4%), chest wall diseases in 3 patients (0.6%) and esophageal diseases in 2 patients (0.4%). In the group of lung disease the most commonly used procedures were the lung biopsy in order to diagnose diffuse pulmonary disease and the indeterminate solitary nodule resection. Among the occurrences of pleural diseases, the most commonly used procedures were the pleurodesis with talc (talc poudrage) for the treatment of recurrent pleural effusion, the driven pleura biopsy and debridment or decortication of trapped lung in cases of pleural empyema. Concerning the mediastinal diseases, the pathology which was most frequently treated by VATS was the recurrent pericardic effusion through partial pericardiectomy. Among the patients presenting chest traumatic diseases, the VATS was used to explore thoracoabdominal penetrating injuries, to control bleeding, to remove clotted hemothorax, to suture diaphragm lesions and to remove intrapleural foreign bodies. Out of 497 procedures, there were 28 convertions to thoracotomy (5.7%) and two deaths occurred all over the cases. The complications, limitations and growth related to this method as well as a future overview of the VATS in Brazil will be presented.
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether atrial natriuretic peptide (ANP) or brain natriuretic peptide (BNP) could be a useful alternative diuretic for patients post cardiac surgery. Altogether more than 250 papers were found using the reported search, of which eight RCTs represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that the RCTs consistently showed a diuretic effect with increased creatinine clearance, and increased urine volume and reduced usage of conventional diuretics. Lower urea and creatinine levels were also found postoperatively and also reduced decreases in glomerular filtration rate compared to placebo, both in studies of patients with preoperatively normal renal function and those who had impaired function. In addition, two studies found a reduction in the incidence of AF, and renin/aldosterone levels were lower. The NAPA trial of 272 CABG patients with LV dysfunction was the only study to show a shorter ICU stay and reduced early mortality with nesiritide compared to placebo.
A 36-year-old intravenous drug abuser presented with an aortic root abscess and partial rupture of the posteromedial papillary muscle. Following aortic and mitral valve replacement, histological and microbiological analysis of the papillary muscle demonstrated methicillin-sensitive Staphylococcus aureus infection. doi: 10.1111/jocs.12241 (J Card Surg 2014;29:213–215)
Abstract Three patients with lung carcinoid related Cushing's syndrome (LCRCS) treated at Frenchay Hospital, Bristol between 1984 and 1994 are described. The first patient presented with hyperpigmentation 13 years after bilateral adrenalectomy. The second patient had no recurrence or metastases 14 years after removal of a typical carcinoid tumour. The last patient survived nine years after diagnosis of liver metastasis. The possibility of LCRCS should be considered in every patient proved to have Cushing's disease and bilateral adrenal enlargement on abdominal computed tomography. Biochemical sets of investigation (for example, adrenocorticotrophic hormone (ACTH) stimulation, dexamethasone suppression, and metyrapone response) could be misleading and should not be relied upon solely. Search for an ectopic ACTH source should be called off only when ACTH has been demonstrated in the surgically removed specimen, and most importantly, when the serum ACTH concentration returns to normal after surgery. Lung carcinoid tumours are compatible with long survival, and liver metastasis could prove indolent and slowly growing.
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