Controversies in the Surgical Management of Sigmoid Diverticulitis

The timing and appropriateness of surgical treatment of sigmoid diverticular disease remain a topic of controversy. We have reviewed the current literature on this topic, focusing on issues related to the indications and types of surgery. Current evidence would suggest that elective surgery for diverticulitis can be avoided in patients with uncomplicated disease, regardless of the number of recurrent episodes. Furthermore, the need for elective surgey should not be influenced by the age of the patient. Operation should be undertaken in patients with severe attacks, as determined by their clinical and radiological evaluation

Alcohol consumption and cardiovascular disease: exploring causality using classical observational and Mendelian randomisation approaches

Background Observational epidemiological studies have consistently demonstrated a lower risk of ischaemic heart disease (IHD) and ischaemic stroke (IS) among moderate compared with non-drinkers, and heterogeneous associations of heavy alcohol intake with these cardiovascular disease (CVD) outcomes. However, the causal nature of these associations remains controversial, and potential mechanisms are not well understood. Methods The UK Biobank is a prospective study of 502,536 adults aged 40-69 years enrolled between 2006 and 2010. For observational analyses, 180,565 White male participants free of baseline CVD were included in Cox regression analyses to estimate risk of incident IHD or IS associated with self-reported baseline alcohol intake, to explore the impact of measurement error, confounding, and reverse causality bias, accounting for these where possible, and to estimate mediating pathways. A Mendelian randomisation (MR) analysis was conducted among 148,488 unrelated male participants with White British ancestry using an externally-weighted genetic instrument based on 93 SNPs associated with alcohol intake. Logistic regression was used to estimate the associations of genetically-predicted log alcohol intake with incident and prevalent IHD and IS. Localised average causal effect (LACE) estimation was used to assess linearity of the MR associations. Results The mean (SD) age of participants was 57 (8) years, and 80% consumed alcohol at least weekly. The age-adjusted hazard ratio (HR) for the association of lifetime abstention versus moderate alcohol intake (0.1-14 units/week) with IHD (1918 events) was attenuated from 1.27 (95%CI 1.06-1.51) to 1.11 (0.85-1.45) after adjustment for confounding by SES, smoking, diet, physical activity, and region, and exclusion of sources of reverse causality bias including reduced-intake drinkers and those with long-standing illness or disability; for IS (499 events), the corresponding HR increased from 1.31 (0.94-1.83) to 1.74 (1.10-2.73), but there were too few events for reliable conclusions. The association of heaviest (>42 units/week) versus moderate alcohol intake with IHD was null (0.92; 0.80-1.07), and with IS was positive (1.38; 1.05-1.82); these associations were mediated mainly by an inverse mediating effect of HDL-c (stronger for IHD than IS) and positive mediating effects of systolic blood pressure (SBP), body mass index (BMI) and, for IS, atrial fibrillation (AF). The MR analyses provided weak evidence that higher alcohol intake causally increases risk of IHD (OR per doubling of genetically-predicted alcohol intake 1.09, 95% CI 1.01-1.19, p=0.035), with borderline evidence of non-linearity (p=0.027) (14,253 events). There was no evidence of a casual association between alcohol intake and risk of IS (OR per doubling of genetically-predicted alcohol intake 1.08, 95% CI 0.90-1.30, p=0.383) but this analysis was not well-powered (2,651 events). Conclusion Classical observational and MR analyses support the hypothesis that the lower observed risk of CVD among moderate drinkers compared with non-drinkers is not causal, and that the association is largely attributable to residual observational biases, particularly reverse causality bias related to longstanding illness or disability among lifetime abstainers. Heterogeneous associations of heavy alcohol intake with IHD and IS may be attributable to differential mediating effects, including those of HDL-c and AF (although the possibility of a causal role for HDL-c is uncertain).</p

Extra-adrenal perirenal myelolipoma. A case report and review of literature

Myelolipomas are rare tumours which are most commonly found in association with the adrenal glands. However, extra-adrenal sites have been described, but limited to case reports. They are characterized by a normal adrenal gland function and absence of haematopoesis which differentiates them from extramedullary haematopoetic tumours. We present a rare case of perirenal extra-adrenal myelolipoma and we review the imaging characteristics and management options for this condition

C-reactive Protein: Adjunct to Cardiovascular Risk Assessment

ABSTRACT Objectives: The study aimed to investigate whether elevated plasma high sensitivity C-reactive protein (hs-CRP) levels are independently associated with an increased risk of cardiovascular disease (CVD) and to then assess the effectiveness of the addition of hs-CRP testing to cardiovascular risk assessment by standard lipid screening. Methods: A retrospective hospital-based case-control study was designed. All patients attending Cross Crossing Medical Centre (CCMC) for routine cardiovascular assessment or emergency treatment were included. Cases were defined as patients with a cardiovascular event and controls as those without an event. Data collected included blood measurements of hs-CRP and cholesterol, demographic data, drug and risk factor history. Results: Odds ratio of 1.84 (95% CI 1.00, 3.38) indicated that a patient with elevated hs-CRP is 1.84 times more at risk of CVD than one with normal hs-CRP. Additionally, the association between hs-CRP and CVD was found to be independent of the other risk factors (p = 0.058). Hs-CRP ranked fourth as an indicator of risk above smoking and diabetes, and patients with both high hs-CRP and high cholesterol (OR = 9.5) were 3.5 times more at risk of CVD than someone with high cholesterol alone (OR = 6.0). Conclusions: Hs-CRP testing enhanced the clinical identification of patients at risk of cardiovascular events. It can therefore contribute to timely implementation of effective lifestyle modification and pharmaceutical intervention. Proteína C reactiva: Complemento para la Evaluación del Riesgo Cardiovascular RESUMEN Objetivos: El estudio apuntó a investigar si los niveles de proteína C reactiva (PCR-hs) de alta sensibilidad de plasma elevado están independientemente asociados con el aumento del riesgo de la enfermedad cardiovascular (ECV), y luego evaluar la efectividad de añadir la prueba PCR-hs para la evaluación del riesgo cardiovascular mediante detección (screening) estándar de lípidos. Métodos: Se diseñó un estudio caso-control retrospectivo con sede en el hospital. En el mismo fueron incluidos todos los pacientes que asistían al Centro Médico Cross Crossing (CCMC) para una evaluación cardiovascular de rutina o para tratamiento de urgencia. Los casos fueron definidos como pacientes con controles y eventos cardiovasculares, o sin un evento. Los datos recogidos incluyeron mediciones sanguíneas de PRC-hs y colesterol, datos demográficos, historia de factores de riesgo y de drogas. Resultados: El odds ratio de 1.84 (95% CI 1.00, 3.38) indicó que un paciente con PCR-hs elevado tiene un riesgo de ECV 1.84 veces mayor que uno con PCR-hs normal. Además, se halló que la asociación entre el PCR-hs y la ECV era independiente de los otros factores de riesgo (p = 0.058). La PCR-hs alcanzó el cuarto lugar como indicador de riesgo, por encima del hábito de fumar y la diabetes, y los pacientes con alto PCR-hs y alto colesterol (OR = 9.5) presentaban riesgo de ECV 3.5 veces mayor que aquellos que sólo tenían colesterol alto (OR = 6.0). Conclusiones: Las pruebas de PCR-hs mejoraron la identificación clínica de pacientes con riesgo de eventos cardiovasculares. Por lo tanto, estas pruebas pueden contribuir a implementar oportunamente una modificación para un estilo de vida y una intervención farmacéutica que sean efectivos