Jewish World Review Oct. 4, 2002 / 28 Tishrei, 5763
By Robert A. Wascher, M.D., F.A.C.S.
http://www.NewsAndOpinion.com |
The results of an international study comparing surgical bypass of multiple
diseased coronary arteries with minimally invasive angioplasty and coronary
artery stenting is reported in this week's issue of the journal Lancet.
The
Stent or Surgery (SoS) trial involved 53 hospitals throughout Europe and
Canada, and randomized 500 patients with multiple vessel coronary artery
disease to coronary artery bypass surgery (CABG), and 488 patients to
percutaneous transluminal coronary angioplasty with coronary artery stenting
(PTCA-CAS). CABG requires general anesthesia, surgical entry into the
chest, and the use of a heart bypass pump. PTCA-CAS, on the other hand, is
performed using local anesthesia and mild sedation, and involves the passage
of a special catheter through an artery in the thigh or upper arm. During a
CABG operation, the surgeon uses arteries in the chest or/and veins in the
legs to bypass the clogged segments of the coronary arteries altogether.
PTCA-CAS, on the other hand, employs a tiny expandable balloon to expand the
narrowed coronary arteries. An expandable metallic stent is then left
behind within the interior of the coronary arteries to help maintain
patency. This study was performed because earlier studies of PTCA alone
were associated with a high risk of recurrent narrowing (stenosis) of
coronary arteries following angioplasty.
All patients in this study were followed for at least one year after
undergoing either PTCA-CAS or CABG, with more than half of the patients
receiving follow-up for two or more years. The researchers in this study
found that 21% of the patients who underwent PTCA-CAS required subsequent
repeat procedures for restenosis of the coronary arteries during this
relatively brief follow-up period, while the patients who received CABG
required revascularization procedures in 6% of cases. There was also a
modest but significant difference in the likelihood of death between the two
patient groups. Among the PTCA-CAS group, 5% of patients died during the
study, while only 2% of the CABG patients died.
The authors concluded that the addition of coronary artery stenting to PTCA
reduces the need for coronary artery revascularization when compared to
results obtained in previous studies looking at PTCA alone. However,
patients with multiple diseased coronary arteries who undergo PTCA-CAS still
appear to have a higher incidence of requiring additional procedures to
revascularize restenosed coronary arteries than similar patients who are
treated with CABG. The study also identified a nearly three-fold increase
in the risk of dying among the PTCA-CAS patients when compared to the CABG
patients. While nobody looks forward to having their chest cracked open,
their heart stopped, and their coronary arteries bypassed, it appears that
CABG remains a superior treatment for patients with coronary artery disease
involving multiple vessels. As the technology for preventing restenosis
following coronary artery stenting continues to improve, I predict that the
time will come when PTCA-CAS will be as effective and as durable as CABG (if
not more so). At the same time, recent advances in minimally invasive CABG
on the beating heart, and without need for a heart bypass machine, may
continue to tip the scale in favor of CABG some time to come.
BEST WAY TO DIAGNOSE APPENDICITIS?
The trouble with this scenario is two-fold.
First of all, other disease processes within the abdomen can cause nearly
identical symptoms. For example, swelling of the lymph nodes near the
appendix after a viral or bacterial infection is a notorious and common
cause of "pseudoappendicitis." Secondly, the inflamed appendix, it would
appear, doesn't always read the classical surgical texts regarding how it
should behave. Patients with bona fide appendicitis may present with many
variations in the location, timing, severity and quality of their pain, and
may present with other symptoms as well, making the diagnosis even more
challenging. Over the past 5 years, ultrasound and CT scans have been
touted by some experts as valuable aids in making-or excluding-the diagnosis
of appendicitis. Proponents of this expensive high tech approach cite the
10-15% incidence of a normal appendix among male patients undergoing
appendectomy when clinical diagnosis alone was used. Women patients fare
even worse when the surgeon relies upon clinical considerations alone, with
some studies reporting a 40-50% incidence of an unremarkable appendix at the
time of surgery. On the other hand, since so many patients with suspected
appendicitis will ultimately prove to have some other condition (and, often,
a condition that does not require surgery), opponents of the routine use of
ultrasound or CT scanning claim that too many scarce and expensive resources
will be wasted on too many patients.
In this week's journal Gastroenterology, 350 consecutive patients who
presented to the emergency room with suspected appendicitis participated in
a research study that was designed to resolve this ongoing controversy. All
participating patients were categorized according to the surgeons' degree of
clinical suspicion for a diagnosis of appendicitis. All patients then
underwent ultrasound evaluation of their abdomen by a radiologist. As a
surgeon, it pains me somewhat to see that, according to this study, the
radiologists fared quite a bit better than their surgeon colleagues. Among
the patients deemed to be at low clinical risk of having appendicitis, 10%
actually did have the disease. Among the intermediate clinical probability
group of patients, 24% had a hot appendix. Within the group of patients
that the surgeons were most convinced of the diagnosis of appendicitis, only
65% of the patients actually had an inflamed appendix, while 18% had some
other identifiable cause for their belly pain, and 17% were never found to
have any abnormal conditions. Using ultrasound, the radiologists were able
to accurately make the diagnosis of appendicitis in 98% of the patients who
actually ended up having the disease, and incorrectly made a diagnosis of
appendicitis in only 2% of the patients who turned out to have a normal
appendix, for an overall diagnostic accuracy of 98%! These are pretty
impressive numbers, and so, at least based upon this study, the radiologists
appear to have scored better in making an accurate preoperative diagnosis
when compared to the surgeons. I will add two caveats, however. Firstly,
performing a high quality ultrasound scan is a subjective and complex
process, and it really does take a very skilled and experienced radiologist
to reproduce the level of diagnostic accuracy achieved in this study.
Secondly, many hospitals not only do not have radiologists with a lot of
experience in making diagnosing appendicitis with ultrasound, but finding
such a rare creature late at night in the hospital (i.e., when patients are
rolling into the ER because their abdominal pain is keeping them awake) is
often an impossible task. Still... I have to hand it to the radiologists
participating in this study, as their results are very impressive.
ANTIOXIDANTS & THE RISK OF STOMACH CANCER
There is even a study that
revealed an apparent increase in the risk of lung cancer among smokers who
also took beta carotene supplements. Now, a new study in Gastroenterology
takes a look at the effects of dietary antioxidants on the risk of stomach
cancer. A total of 505 patients with newly diagnosed gastric cancer, and
1,116 "control patients" without cancer, were enrolled into this study. All
participating patients were then carefully interviewed to ascertain their
dietary habits. The researchers then calculated the antioxidant potential of
each patient's diet based upon the content of specific vegetables and fruits
that they commonly consumed. Briefly, the study showed that patients with
the highest intakes of antioxidant-rich plant-based foods, overall, had a
35% lower incidence of stomach cancer than patients with low levels of
antioxidant-rich diets. When the incidence of smoking among the two groups
was accounted for, the inverse relationship between dietary antioxidants and
the risk of gastric cancer became even more pronounced. Patients who had
never smoked and who had the highest levels of antioxidants in their diet
had a 56% lower risk of gastric cancer when compared to the other study
patients.
While dietary survey studies are somewhat subjective by their nature (as
they rely upon the memory and honesty of the test subjects), they are still
powerful tools for assessing the impact of dietary factors upon the
development of diseases that may be linked with eating and drinking habits.
One can, therefore, infer from this study that a diet rich in antioxidants
may be associated with a reduced risk of developing stomach cancer and that
smoking, particularly in the presence of low levels of antioxidants in the
diet, may increase the risk of gastric cancer.
JWR contributor Dr. Robert A. Wascher is a senior research fellow in molecular & surgical oncology at
the John Wayne Cancer Institute in Santa Monica, CA.
Comment by clicking here.
Coronary Artery Disease: Stent or Surgery?
For centuries, surgeons have debated the most accurate methods for making
the clinical diagnosis of appendicitis. Classical surgical texts describe
the onset of appendicitis heralding with vague periumbilical pain which
then, at some later point, begins to migrate or localize towards the right
lower area of the abdomen.
The proper role, if any, of dietary antioxidant nutrients in the prevention
of cancer is a hotly debated subject. There are numerous studies showing
either a reduction in the incidence of cancer with an antioxidant-rich diet
or no change in the incidence of cancer.
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