Variability in meta-analytic results concerning the value of cholesterol reduction in coronary heart disease: a meta-meta-analysis.

Despite official support for the efficacy of cholesterol reduction, considerable controversy exists, and meta-analyses of this topic have produced conflicting results. The authors assessed the variability of meta-analyses, evaluating the cardiovascular value of cholesterol reduction while attempting to explain the variability. Metaanalyses were identified by electronic search and citation tracking. Included were those conducted prior to 1995 that dealt with cholesterol reduction and total mortality, cardiovascular mortality, or nonfatal cardiovascular disease. In addition to extracting odds ratios for total mortality, cardiovascular mortality, and nonfatal cardiovascular disease, the authors encoded methodological variables, publication variables, and data concerning investigators' backgrounds. Twenty-three meta-analyses were reviewed, and 15 concluded that cholesterol reduction was beneficial. Summary odds ratios for total mortality were heterogeneous, generally failing to support the value of cholesterol reduction. Odds ratios depended on inclusion criteria and investigator variables. Odds ratios for cardiovascular mortality and for nonfatal cardiovascular disease were more homogeneous and supported the value of cholesterol reduction. Methodologically better meta-analyses tended to report more beneficial odds ratios. Although "supportiveness" of the value of cholesterol reduction was associated with inclusion/exclusion criteria and publication variables, the primary outcome variable related to supportiveness was the statistical significance of the odds ratios for cardiovascular mortality.

An office approach to the diagnosis of chronic cough.

Chronic cough is a common problem in patients who visit family physicians. The three most common causes of chronic cough in those who are referred to pulmonary specialists are postnasal drip, asthma and gastroesophageal reflux. The initial treatment of patients with cough is often empiric and may involve a trial of decongestants, bronchodilators or histamine H2 antagonists, as monotherapy or in combination. If a therapeutic trial is not successful, sequential diagnostic testing including chest radiograph, purified protein derivative test for tuberculosis, computed tomography of the sinuses, methacholine challenge test or barium swallow may be indicated. By using a standard protocol for diagnosis and treatment, 90 percent of patients with chronic cough can be managed successfully in the family physician's office. However, in some cases it may take three to five months to determine a diagnosis and effective treatment. For the minority of patients in whom this diagnostic approach is unsuccessful, consultation with a pulmonary specialist is appropriate.

Hispanic American elders: caregiving norms surrounding dying and the use of hospice services.

The purpose of this review is to (1) provide an overview of health and demographic characteristics common to the Hispanic elder population, (2) address family caregiving issues surrounding the terminal illness of a loved one, (3) understand resource utilization by Hispanic elderly and their family caregivers, and (4) make recommendations for the provision of information and education about hospice services. Case examples will illustrate patterns and themes unique to Hispanic caregiving.

Use of histomorphometry in the assessment of fatal vertebral artery dissection.

AIM: To assess morphometrically the structural changes, which occur with ageing, along the length of the vertebral artery. METHODS: A series of 36 vessels were removed at necropsy from subjects aged between 9 months and 86 years. Image analysis was used to measure the medial width, the circumference, the intimal: medial area ratio and the adventitial: medial area ratio along each artery. The artery from a case of fatal vertebral artery dissection, which occurred after a game of cricket and then chiropractic neck manipulation, was also examined in the same manner. The proteoglycan accumulation in the media was quantified using an eyepiece graticule. RESULTS: The vertebral arteries were, on average, larger around the origin of the vessel from the subclavian artery, and the adventitia were relatively thicker at this point, and also after piercing the dura mater. The media were much thinner within the intracranial segment and pronounced intimal thickening occurred with increasing age. The dissected artery showed undoubtable pre-existent structural abnormalities, in the form of massive proteoglycan accumulation, which predisposes an artery to dissection. CONCLUSIONS: These data should help pathologists faced with the task of assessing the underlying structural integrity of the vessel wall in cases of vertebral artery injury.

IgM-associated primary diffuse mesangial proliferative glomerulonephritis: natural history and prognostic indicators.

Fifty-four adults with primary mesangial proliferative glomerulonephritis and IgM deposition were observed for a minimum of three years or until end-stage renal failure. The actuarial renal survival was 80 per cent at 5 years and 64 per cent at 10 years; multivariate analysis identified microscopic haematuria, extent of mesangial proliferation and global glomerular sclerosis as independent prognostic indicators.

Chronic extradural haemorrhage. A case report and brief literature review.

A case of chronic extradural haemorrhage with a presumed time interval of 5-6 weeks between injury and diagnosis at postmortem examination is presented. The literature relating to this entity has been reviewed, and relevant features commented upon, including time intervals, age, sex, location, clinical features, pathological findings, associated skull fractures, mechanisms involved, and the source of the bleeding.

Pathology of common bile duct stenosis in cystic fibrosis.

A case of cystic fibrosis complicated by common bile duct stenosis is described. Surgery successfully relieved the obstruction, but was complicated by Candida septicaemia. The previously unreported histological abnormalities of the common bile duct are discussed.

Sequential development of systemic vasculitis with anti-neutrophil cytoplasmic antibodies complicating anti-glomerular basement membrane disease.

Anti-neutrophil cytoplasmic antibodies (cANCA) were detected in 3 patients with anti-glomerular basement membrane (anti-GBM) disease. All 3 cases presented late in their clinical course, with severe renal involvement and alveolar hemorrhage. Anti-neutrophil cytoplasmic antibodies were associated with clinical features outwith the lungs and kidneys; in one case cANCA were initially absent but subsequently developed concurrently with the clinical appearance of systemic vasculitis as the anti-GBM antibody titer was falling. These findings confirm that cANCA can complicate anti-GBM disease and suggest that cANCA may identify a distinct subset of patients with anti-GBM disease, supporting a pathogenic role for cANCA in the development of systemic vasculitis.

Fundus changes in mesangiocapillary glomerulonephritis type II: clinical and fluorescein angiographic findings.

Previously we have demonstrated a deposit in Bruch's membrane in a single case of mesangiocapillary glomerulonephritis type II. We studied a group of patients with this disease and described extensive clinical and fluorescein angiographic abnormalities, which were in marked contrast to the findings in a group of patients with other forms of glomerulonephritis. This finding contributes to our understanding of the pathophysiology of the complex of the retinal pigment epithelium, Bruch's membrane, and choriocapillaris.

Goodpasture's syndrome in a patient with two endocrine tumours.

We describe the occurrence of two anatomically separate and histologically distinct endocrine tumours of bronchus and pancreas in a 64 year old woman with biopsy and serology proven Goodpasture's syndrome. The association between anti-glomerular basement membrane antibody disease and multiple endocrine tumours has not been reported previously; possible pathogenetic mechanisms are discussed.