 The enigma of primary frozen shoulder has been solved, says a
review in the Annals of the Royal College of Surgeons of England
(1997;79:210-3). It is due to a fibrous contracture of the
rotator interval and the coracohumeral ligament of the shoulder joint
by tissue that shows the same histological features as in Dupuytren's
contracture. Logically, therefore, the treatment should be
similar - surgical release of the contracture. Monkeypox is related to smallpox and cowpox and can be
transmitted to humans, but transmission between people is unusual. In a
recent outbreak of the disease in people living in Zaire, at least 71
cases occurred and there were six deaths (Eurosurveillance
1997;2:33-50). This is the largest cluster of human cases ever
reported, and transmission between people seems to have been
responsible for most of the spread of the disease. Vaccinia vaccination
protects against monkeypox and may need to be considered if further
outbreaks occur. Women who have symptoms of illness that they attribute to
silicone breast implants do seem to feel better after the implants have
been removed - or that was the experience of 24 out of 25 women treated
in Alabama (The American Surgeon 1997;63:421-9). In 20
of the 25, the silicone implants were replaced with new ones filled
with saline: only one woman was dissatisfied with the results of
revision surgery two years afterwards. Botulinum A toxin has established its place in the treatment of
focal dystonias. A possible further use is in the treatment of sweaty
hands. A report in the British Journal of Dermatology
(1997;136:548-52) describes a double blind trial in 11 patients in whom
one hand was treated and the other used as the control. In eight of the
11 the reduction in sweating was sufficiently impressive for them to
ask for the treatment to be continued after the end of the trial. Human T cell lymphotropic virus type 1 was discovered before
HIV; it is the cause of T cell leukaemia and tropical spastic paresis,
and infection can be transmitted by blood transfusion. Few transfusion
authorities screen for the virus, however, arguing that it is too rare.
The issue is being aired in the Medical Journal of Australia
(1997;166:454-5), which is calling for a reappraisal with
respect to this and other viruses that may be transmitted through blood
transfusion, including parvovirus B19 and possibly herpes virus 8.
Should not the community at large be given a voice in deciding what
price it is prepared to pay for blood to be kept as safe as possible? Trials of screening tests for cancer need enormous numbers if
whole populations (as opposed to high risk cohorts) are studied. A
review in Cancer (1997;79:1740-6) says that for a trial
to have a 90% power to detect a 25% decrease in mortality from cancer
of the stomach, 437 000 people would need to be recruited; for cancer
of the rectum the total needed would be 719 000 and for cancer of the
larynx 1 700 000. In some ways colchicine is a hangover from mediaeval medicine,
but it still has some clinical uses. A report in Mayo Clinic
Proceedings (1997;72:201-9) describes 22 patients with
idiopathic pulmonary fibrosis treated with the drug. They did just as
well as historical controls treated with corticosteroids and suffered
far fewer side effects. A symposium on food allergy reported in the Journal of
the Royal Society of Medicine (1997;90(suppl 30):9-14)
concludes that a few children with atopic dermatitis may benefit from
being given a restricted diet. It prefers elimination diets to allergy
tests in identifying those children most likely to respond and comments
that the best results come in children who start treatment in the first
12 months of life. A cohort of 252 patients brought to an emergency department
after syncope was used to develop a risk classification which was then
used prospectively on a further 374 patients (Annals of
Emergency Medicine 1997;29:459-66). The four predictors of high
risk were an abnormal electrocardiogram, a history of a ventricular
arrhythmia, a history of congestive heart failure, and age over 45.
Patients with three or four risk factors had a 57% incidence of an
overt arrhythmia or death within 12 months. Repair of a perforated peptic ulcer seems to be one of the
operations that can be carried out safely with laparoscopic techniques
(Journal of the Royal College of Surgeons of Edinburgh
1997;42:92-4). A few patients with large perforations or continued
bleeding may need conversion to an open laparotomy, but most can be
expected to recover after laparoscopy, returning to normal activities
within 10 days. Hypercoagulability due to inherited effects in the natural
anticoagulant pathways usually presents clinically as venous
thromboembolism (Annals of Internal Medicine
1997;126:638-44). As many as one fifth of patients with venous
thromboses can be shown to have one of the genetic abnormalities of
coagulation factors.
Rheumatoid factors were first described 60 years ago, but
research has answered only a few questions about their functions and
effects (Annals of the Rheumatic Diseases
1997;56:281-6). They may have some physiological actions, including
playing a part in the clearance of immune complexes. What has become
apparent is that they are more than just markers of rheumatoid
arthritis - they are found in other autoimmune diseases and in some
chronic infections such as Lyme disease. A review of aplastic anaemia in the New England
Journal of Medicine (1997;336:1365-72) comments that in Europe
and North America around a quarter of cases are attributable to drugs.
When the anaemia develops after hepatitis this is usually "non a, non
B, non C, and non G." Aplastic anaemia is more common in the Far East
than in Europe; in countries such as Thailand, where hepatitis viruses
are widespread, it is also associated with poverty and (somewhat
mysteriously) rice farming. Volcanic eruptions may cause more psychological stress
in children with asthma than in the rest of the child population
(New Zealand Medical Journal 1997;110:145-7). The
explanation seems to be that the children and their parents expect that
volcanic dust will precipitate attacks of asthma. Psychological support
should be given by health professionals at an early stage in the
eruption.
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