"Test me and treat me" - attitudes to vitamin D deficiency and supplementation: a qualitative study

© 2015 BMJ Open, "Test me and treat me"-attitudes to vitamin D deficiency and supplementation: a qualitative study. This manuscript version is made available under the Creative Commons Attribution Licens

Minimally invasive surgery and cancer: controversies part 1

Perhaps there is no more important issue in the care of surgical patients than the appropriate use of minimally invasive surgery (MIS) for patients with cancer. Important advances in surgical technique have an impact on early perioperative morbidity, length of hospital stay, pain management, and quality of life issues, as clearly proved with MIS. However, for oncology patients, historically, the most important clinical questions have been answered in the context of prospective randomized trials. Important considerations for MIS and cancer have been addressed, such as what are the important immunologic consequences of MIS versus open surgery and what is the role of laparoscopy in the staging of gastrointestinal cancers? This review article discusses many of the key controversies in the minimally invasive treatment of cancer using the pro–con debate format

Status Update and Interim Results from the Asymptomatic Carotid Surgery Trial-2 (ACST-2)

Objectives: ACST-2 is currently the largest trial ever conducted to compare carotid artery stenting (CAS) with carotid endarterectomy (CEA) in patients with severe asymptomatic carotid stenosis requiring revascularization. Methods: Patients are entered into ACST-2 when revascularization is felt to be clearly indicated, when CEA and CAS are both possible, but where there is substantial uncertainty as to which is most appropriate. Trial surgeons and interventionalists are expected to use their usual techniques and CE-approved devices. We report baseline characteristics and blinded combined interim results for 30-day mortality and major morbidity for 986 patients in the ongoing trial up to September 2012. Results: A total of 986 patients (687 men, 299 women), mean age 68.7 years (SD ± 8.1) were randomized equally to CEA or CAS. Most (96%) had ipsilateral stenosis of 70-99% (median 80%) with contralateral stenoses of 50-99% in 30% and contralateral occlusion in 8%. Patients were on appropriate medical treatment. For 691 patients undergoing intervention with at least 1-month follow-up and Rankin scoring at 6 months for any stroke, the overall serious cardiovascular event rate of periprocedural (within 30 days) disabling stroke, fatal myocardial infarction, and death at 30 days was 1.0%. Conclusions: Early ACST-2 results suggest contemporary carotid intervention for asymptomatic stenosis has a low risk of serious morbidity and mortality, on par with other recent trials. The trial continues to recruit, to monitor periprocedural events and all types of stroke, aiming to randomize up to 5,000 patients to determine any differential outcomes between interventions. Clinical trial: ISRCTN21144362. © 2013 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved

Second asymptomatic carotid surgery trial (ACST-2): a randomised comparison of carotid artery stenting versus carotid endarterectomy

Background: Among asymptomatic patients with severe carotid artery stenosis but no recent stroke or transient cerebral ischaemia, either carotid artery stenting (CAS) or carotid endarterectomy (CEA) can restore patency and reduce long-term stroke risks. However, from recent national registry data, each option causes about 1% procedural risk of disabling stroke or death. Comparison of their long-term protective effects requires large-scale randomised evidence. Methods: ACST-2 is an international multicentre randomised trial of CAS versus CEA among asymptomatic patients with severe stenosis thought to require intervention, interpreted with all other relevant trials. Patients were eligible if they had severe unilateral or bilateral carotid artery stenosis and both doctor and patient agreed that a carotid procedure should be undertaken, but they were substantially uncertain which one to choose. Patients were randomly allocated to CAS or CEA and followed up at 1 month and then annually, for a mean 5 years. Procedural events were those within 30 days of the intervention. Intention-to-treat analyses are provided. Analyses including procedural hazards use tabular methods. Analyses and meta-analyses of non-procedural strokes use Kaplan-Meier and log-rank methods. The trial is registered with the ISRCTN registry, ISRCTN21144362. Findings: Between Jan 15, 2008, and Dec 31, 2020, 3625 patients in 130 centres were randomly allocated, 1811 to CAS and 1814 to CEA, with good compliance, good medical therapy and a mean 5 years of follow-up. Overall, 1% had disabling stroke or death procedurally (15 allocated to CAS and 18 to CEA) and 2% had non-disabling procedural stroke (48 allocated to CAS and 29 to CEA). Kaplan-Meier estimates of 5-year non-procedural stroke were 2·5% in each group for fatal or disabling stroke, and 5·3% with CAS versus 4·5% with CEA for any stroke (rate ratio [RR] 1·16, 95% CI 0·86–1·57; p=0·33). Combining RRs for any non-procedural stroke in all CAS versus CEA trials, the RR was similar in symptomatic and asymptomatic patients (overall RR 1·11, 95% CI 0·91–1·32; p=0·21). Interpretation: Serious complications are similarly uncommon after competent CAS and CEA, and the long-term effects of these two carotid artery procedures on fatal or disabling stroke are comparable. Funding: UK Medical Research Council and Health Technology Assessment Programme

Relationship between FEV1 reduction and respiratory symptoms in the general population

Obstructive airways diseases typically present with dyspnoea, cough and wheeze, and are defined by a reduced forced expiratory volume in one second (FEV1)/ forced vital capacity (FVC) ratio. Traditionally, however, the severity of chronic obstructive pulmonary disease is graded by the FEV1 % predicted rather than the FEV1/FVC ratio, whilst other potentially valid measures of FEV1 impairment, such as the absolute difference of FEV1 from predicted or the absolute level of FEV1, tend not to be used. The authors have therefore explored the relationship between these different measures of FEV1 impairment and chronic respiratory symptoms in a general population sample. FEV1 and FVC were measured and questionnaire data were obtained on cough, wheeze, shortness of breath and general self-reported breathing trouble in a cross-sectional survey of 2,633 adults aged 18-70 yrs from a district of Nottingham, UK. Odds ratios for each symptom were calculated for declining levels of absolute FEV1, FEV1 % pred, absolute difference of FEV1 from predicted, and FEV1/FVC ratio. They were plotted to display the shape and strength of these relationships before and after adjustment for each other measure. The odds of symptoms increased with declining levels of all FEV1 measures, particularly for wheeze and general breathing trouble. Although this study was not sufficiently powerful to detect significant differences between measures, these relationships were consistently strongest, before and after adjustment, for FEV1 % pred, particularly below a threshold of similar to75%. The authors conclude that forced expiratory volume in one second % predicted appears to be the measure of airflow impairment most closely associated with chronic respiratory symptoms in the general population

High-pressure structural evolution of a perovskite solid solution (La1-x,Ndx)GaO3

The structural evolution with pressure of six perovskites in the system La1−xNdxGaO3 with x=0.00, 0.06, 0.12, 0.20, 0.62 and 1.00 have been determined by single-crystal diffraction. At room pressure, all six samples have Pbnm symmetry. The room-pressure bulk moduli vary only slightly with composition, between K0T=169(4) and 177(2) GPa, with View the MathML source. As pressure is increased there is significant compression of the octahedral Ga–O bonds, the tilts of the GaO6 octahedra decrease and the structures evolve towards higher symmetry. At room conditions the average Ga–O bond length increases with increasing compositional parameter x. However, the GaO6 become stiffer with increasing x; the Ga–O bonds thus become stiffer as they become longer. Bond strengths in the octahedra in perovskites are therefore not a simple function of bond lengths but depend also upon the extra-framework cation. Phase transitions to R-3c symmetry occur at 2.2 GPa in end-member LaGaO3, at not, vert, similar5.5 GPa in the x=0.06 sample, at not, vert, similar7.8 GPa for x=0.12, and at not, vert, similar12 GPa for x=0.20. No evidence of the transition in the x=0.62 or 1.00 samples was found by X-ray diffraction to 9.4 or 8.0 GPa, respectively, or by Raman measurements of NdGaO3 up to 16 GPa. The transition pressure therefore increases with increasing Nd content (increasing x) at approximately 0.45 GPa per 0.01 increment in x, at least up to x=0.20. Compression of the R-3c phase of LaGaO3 above the transition results in no significant changes in the tilt angle of the octahedra. The structural behavior of all six samples at high pressures is the result of the GaO6 octahedra being softer than the extra-framework (La, Nd)O12 site. The results therefore demonstrate that the evolution of solid-solution perovskites at high pressures follow the same general principles recently elucidated for end-member compositions. Graphical abstract High-pressure structure determinations of six perovskites on the La1−xNdxGaO3 join show that at La-rich compositions the GaO6 octahedra have much lower bulk moduli, as shown in the figure. This softening of the octahedra drives the high-pressure phase transition from Pbnm to R-3c structures. Full-size imag