Use of dydrogesterone in hormone replacement therapy.

According to the Women's Health Initiative (WHI) study, the most important risks during combined hormone replacement therapy (HRT) are breast cancer, stroke and venous thromboembolism. To date, combinations of estradiol with natural progesterone or its retroisomer dydrogesterone are the only combined HRT regimens for which large case-control or cohort studies show no increase in any of these three risks. Moreover, due to the neutral effect of dydrogesterone on the vascular and metabolic systems, the preventive effect of the estradiol component with respect to myocardial infarction and metabolic syndrome can be maintained if HRT is started early after the menopause. Although a study with the same design as the WHI has not been performed, these results appear to be plausible considering the positive experimental evidence, particularly in the context of breast cancer and cardiovascular risks/benefits. Combination with dydrogesterone avoids endometrial hyperproliferation, maintains the beneficial effects of estradiol (i.e. efficacy against climacteric symptoms and prevention of osteoporotic fractures) and minimizes the most important risks known to be associated with the progestogen components of HRT regimens.

Outcome of treatment of ruptured abdominal aortic aneurysms depending on the type of hospital.

OBJECTIVE: To compare the outcome of patients operated on acutely for ruptured abdominal aortic aneurysms (AAA) or otherwise symptomatic aortic aneurysms in a university hospital and in two county hospitals by the same group of vascular surgeons. DESIGN: Retrospective study. SETTING: 1 university and 2 county hospitals, Sweden. SUBJECTS: 108 patients operated on urgently for AAA, 81 at the university hospital, and 27 at the county hospitals between January 1992 and December 1998. INTERVENTION: Repair of the AAA. MAIN OUTCOME MEASURES: Morbidity and mortality. RESULTS: 21 of the 81 patients having urgent repair of an AAA at the university hospital (26%) had been transferred from the county hospitals. Thirteen patients were not operated on, 7 because of their poor general condition and great age (median 84 years), 3 who refused operation, and 3 in whom the diagnosis was incorrect. During the same time period a further 27 haemodynamically unstable patients were operated on by the same vascular surgeons at the county hospitals. The on-table mortality for patients with ruptured AAA and shock was 5/43 (12%) at the university hospital and 4/27 (15%) at the county hospitals. The corresponding in-hospital rates were 11/43 (26%) and 11/27 (41%). Mortality was significantly higher if the operation was delayed by more than 45 minutes. The incidence of postoperative complications was the same in both hospitals. CONCLUSION: If a patient with a ruptured AAA and shock is admitted to the county hospital and operated on by a specialist vascular surgeon the outcome is fully acceptable. The difference seems to be related to the postoperative period. To what extent the delay caused by the surgeon's journey to the county hospital has any influence on the outcome is not possible to evaluate.

Talonavicular arthrodesis in the rheumatoid foot.

Arthrodesis of the talonavicular joint with a cylindrical dowel was performed in 19 feet in 17 rheumatoid patients with arthritic destruction of the talonavicular joint, but without fixed hindfoot deformity. Osseous union was achieved in 12 feet, but all patients experienced pain relief and no foot showed progressive valgus deformity of the hindfoot during follow-up. Staple fixation seemed to promote osseous union. The procedure, easy to perform and requiring only 6 weeks of immobilization, may, in the absence of fixed hindfoot deformity, supersede triple arthrodesis in rheumatoid patients with hindfoot arthritis.