Capsule endoscopy: impact on clinical decision making in patients with suspected small bowel bleeding.

BACKGROUND AND STUDY AIM: Capsule endoscopy is widely used for diagnosis of small-bowel disease; however, the impact of capsule endoscopy on clinical management remains uncertain. We conducted a prospective study of the impact capsule endoscopy on clinical management decisions in 128 patients with suspected small-bowel pathology. METHODS: Prior to performing each procedure the gastroenterologist predicted the findings of capsule endoscopy and further management based on the clinical history and previous investigations. This prediction was compared with the actual results of capsule endoscopy and the following investigative and therapeutic management. RESULTS: The actual findings of capsule endoscopy and the further management were consistent with clinical prediction in 93/128 patients (73 %) and, irrespective of capsule endoscopy findings, no further procedures were required in 80 % of these patients. In 13 patients (10 %), gastric or colonic pathology was discovered that had not been detected on prior gastroscopy or colonoscopy. Thus, capsule endoscopy findings in the small bowel changed clinical management in 22 patients (17 %). In 4 patients, positive findings on capsule endoscopy that had not been predicted by the examiner prompted referral for abdominal surgery. Conversely, planned surgery was canceled in four other patients. CONCLUSION: In this series of patients referred for capsule endoscopy, small-bowel findings and appropriate clinical management were predicted on clinical grounds alone in approximately three-quarters of patients. Repetition of standard upper and lower endoscopy may be useful in many patients prior to small-bowel imaging. Referral for capsule endoscopy should take into account whether the findings will impact on clinical management; however, capsule endoscopy is mandatory in patients in whom surgery for small-bowel bleeding is intended.

Primary stenting versus primary balloon angioplasty for treating acute myocardial infarction.

BACKGROUND: Balloon angioplasty following myocardial infarction (MI) reduces death, non-fatal MI and stroke compared to thrombolytic reperfusion. However up to 50% of patients experience restenosis and 3% to 5% recurrent myocardial infarction. Therefore, primary stenting may offer additional benefits compared to balloon angioplasty in patients with acute myocardial infarction. OBJECTIVES: To examine whether primary stenting compared to primary balloon angioplasty reduces clinical outcomes in patients with acute myocardial infarction. SEARCH STRATEGY: We searched MEDLINE, EMBASE, Pascal, Index medicus and The Cochrane Controlled Trials Register (The Cochrane Library) from 1979 to March 2002. SELECTION CRITERIA: Randomised controlled trials of primary stenting or balloon angioplasty prior to the invasive procedure; intervention in native coronary arteries within 24 hours after onset of symptoms of myocardial infarction; report of death or reinfarction; and follow-up of at least 1 month. Trials were excluded when randomisation occurred after an invasive procedure and if they exclusively included patients with cardiogenic shock. DATA COLLECTION AND ANALYSIS: Two reviewers independently selected and extracted data from identified trials. Outcomes included mortality, reinfarction, coronary artery bypass grafting, target vessel revascularization, need for vascular repair or blood transfusion. Peto odds ratios were calculated. To explore the stability of the overall treatment effect various sensitivity analyses were performed. MAIN RESULTS: We included nine trials of 4433 participants. Odds ratios for mortality after stenting compared to balloon angioplasty at 30 days, 6 and 12 months were 1.16 (95% CI 0.78 to 1.73), 1.27 (95% CI 0.89 to 1.83), and 1.06 (95% CI 0.77 to 1.45). At 30 days, 6 and 12 months odds ratios for reinfarction after stenting compared to balloon angioplasty were 0.52 (95% CI 0.31 to 0.87), 0.67 (95% CI 0.45 to 1.00), and 0.67 (95% CI 0.45-0.98) and odds ratio for target vessel revascularization after stenting compared to balloon angioplasty were 0.45 (95%CI 0.34 to 0.60), 0.42 (95% CI 0.35 to 0.51), and 0.47 (95% CI 0.38 to 0.57). The odds ratio for post-interventional bleeding complications after stenting compared to balloon angioplasty was 1.34 (95% CI 0.95 to 1.88; test of heterogeneity p > 0.1). AUTHORS' CONCLUSIONS: There is no evidence to suggest that primary stenting reduces mortality when compared to balloon angioplasty. Stenting seems to be associated with a reduced risk of reinfarction and target vessel revascularization, but potential confounding due to unbalanced post-interventional antithrombotic/anticoagulant therapies can not be ruled out on basis of this review.

Percutaneous transluminal coronary angioplasty versus medical treatment for non-acute coronary heart disease: meta-analysis of randomised controlled trials.

OBJECTIVE: To determine whether percutaneous transluminal coronary angioplasty (angioplasty) is superior to medical treatment in non-acute coronary artery disease. DESIGN: Meta-analysis of randomised controlled trials. SETTING: Randomised controlled trials conducted worldwide and published between 1979 and 1998. PARTICIPANTS: 953 patients treated with angioplasty and 951 with medical treatment from six randomised controlled trials, three of which included patients with multivessel disease and pre-existing myocardial infarction. MAIN OUTCOME MEASURES: Angina, fatal and non-fatal myocardial infarction, death, repeated angioplasty, and coronary artery bypass grafting. RESULTS: In patients treated with angioplasty compared with medical treatment the risk ratios were 0. 70 (95% confidence interval 0.50 to 0.98; heterogeneity P<0.001) for angina; 1.42 (0.90 to 2.25) for fatal and non-fatal myocardial infarction, 1.32 (0.65 to 2.70) for death, 1.59 (1.09 to 2.32) for coronary artery bypass graft, and 1.29 (0.71 to 3.36; heterogeneity P<0.001) for repeated angioplasty. Differences in the methodological quality of the trials, in follow up, or in single versus multivessel disease did not explain the variability in study results in any analysis. CONCLUSIONS: Percutaneous transluminal coronary angioplasty may lead to a greater reduction in angina in patients with coronary heart disease than medical treatment but at the cost of more coronary artery bypass grafting. Trials have not included enough patients for informative estimates of the effect of angioplasty on myocardial infarction, death, or subsequent revascularisation, though trends so far do not favour angioplasty.

[Check-up-examinations in internal medicine]. / Der internistische Check-up.

A growing body of evidence supports or rejects preventive interventions in asymptomatic adults. Thus, counseling for smoking cessation and some immunizations have been shown to be cost-effective. Evidence supports screening for body weight (obesity), hypertension, hyperlipidemia, cervical cancer, colorectal cancer and breast cancer. Screening for lung, pancreatic and ovarian cancer has no effect on outcome and should not be performed. Controversial preventive interventions include general screening for diabetes mellitus in the young adult, thyroid disorders and prostate cancer. Physicians should be aware of a possible hidden agenda in patients presenting for a check-up.

[Bone pain and clubbed fingers. Primary hypertrophic osteoarthropathy]. / Knochenschmerzen und Trommelschlegelfinger. Primare hypertrophe Osteoarthropathie.

A 37-year-old-patient was admitted to the medical polyclinic with a history of lower leg pain that had lasted for months. Pronounced clibbed fingers and toes were noted on clinical examination but other wise the patient's general condition was unremarkble. None of the routine tests performed evidenced pathological findings. Radiological examination revealed a lamellar periosteal reaction along both sides of the tibia and fibula consistent with hypertrophic osteoarthropathy. A computed tomogram taken of the thorax to exclude a tumor was inconspicuous. Treatment with nonsteroid antirheumatics resulted in complete eradication of the symptoms. In case of uncertain bone pain together with clubbed fingers, consideration must be given to hypertrophic osteoarthropathy. This condition is usually a secondary manifestation, especially in cases of cardiac or pulmonary disease. The primary or idiopathic forms is rare and has a good prognosis.

[Vaccinations in adults]. / Impfungen bei Erwachsenen.

Immunization practices in adults are based on clinical experience and practice. Recent years have seen advances in several viral and bacterial diseases preventable by immunization. The following article discusses general recommendations regarding immunization practices in adults as well as these advances which have modified the current immunization practices. Immunization guidelines for specific diseases are not given in this article. However, they should be looked up in the guidelines for diagnosis and prevention of infectious diseases published by the Swiss Federal Office of Public Health.