Throughout Minerva's professional lifetime the diagnostic gold
standard for arterial disease has been angiography. Not for much longer
(British Journal of Surgery 1997;84:912-9). Advances in
Doppler ultrasonography with colour flow imaging can now produce
accurate, reliable information on arterial blood flow at no risk to the
patient. Staff will need to be trained in the new techniques, but the
days of painful injections should soon be over.
Between 1982 and 1993 in Britain 5879 people died of AIDS and
388 had full necropsies. These showed that around one quarter of the
patients had HIV encephalitis, and this condition was more common in
intravenous drug users than in other risk groups. The patients with
haemophilia had much the highest incidence of vascular lesions.
A longitudinal study of 1042 men and women aged over 65
(Age and Ageing 1997;26:179-84) found that 221 had
insomnia and one third of these still had persistent problems sleeping
four years later. Of 166 people who had been using prescription
hypnotics at baseline, one third were still doing so at the second
assessment, and the authors conclude that "late life insomnia shows a
level of chronicity incompatible with hypnotic drug therapy as
currently recommended."
The parathyroid glands (first identified during a necropsy on an
Indian rhinoceros at London Zoo in 1850) present a continuing challenge
to surgeons who have to find the diseased gland or glands
(American Surgeon 1997;63:567-72). The current best
functional test is a sestamibi scan, but for many clinicians "the
best way of localising the parathyroid glands is to localise an
experienced parathyroid surgeon."
The National Institutes of Health have just published their
consensus statement on the integration of behavioural and relaxation
approaches into the treatment of chronic pain and insomnia.
Coincidentally, an article in Pain (1997;71:211-2) calls
for people who have dyspareunia to be integrated into the mainstream of
pain research: neither tissue damage nor psychosocial conflict is a
prerequisite for pain during sexual intercourse, which may simply
reflect a more general condition of vaginal hyperalgesia.
Childhood fevers such as chickenpox and measles are more likely
to cause serious illness in adults than in children, as was shown
recently in an outbreak of measles in Greece
(Eurosurveillance 1997;2(7):57-8). Of the 431 reported
cases, 126 were in adults, 79 of whom needed admission to hospital.
Measles pneumonia and hepatitis were more common and more severe in the
adult patients. Seventy six of the 92 adults whose vaccination status
was known had been immunised with monovalent vaccine before the
introduction of the measles, mumps, and rubella vaccine.
The US National Cancer Data Base has recently reported on
96 030 women treated for breast cancers in stage I or II. They were
treated with surgery, which ranged from segmental resection to modified
radical mastectomy, and, depending on the stage and the surgeon, some
were treated with axillary node dissection, radiotherapy, and systemic
chemotherapy (Cancer 1997;80:162-7). The women were not
recruited into randomised trials, but the authors believe that their
data show that within each stage reported survival in patients managed
with breast preservation was equal to or more favourable than that in
patients who had radical surgery.
Sudden cardiac death accounts for half of all deaths from
cardiovascular disease. A paper in Circulation
(1997;95:2694-9) on "the treatment of sudden cardiac death" is
actually concerned with its prevention. Several large clinical trials
are under way in different populations at risk, and these should soon
sort out the relative merits of implantable defibrillators, |gb
blockers, and antiarrhythmic drugs such as amiodarone.
A detailed review of the mechanisms of nausea and vomiting in
the Journal of the Royal Naval Medical Service
(1997;83:31-41) includes one striking phrase: "The spectrum of
problems that give rise to vomiting is very wide, ranging from normal
pregnancy to the bizarre psychopathological aberration of erotic
vomiting at each other." Leaving that to one side, most vomiting is
now treatable with remedies from ginger to 5-HT3 receptor
antagonists.
It is reassuring to read accounts by the clinicians concerned of
treatments that didn't work out too well. The early results of
arthroplasty with a hinged Rotaflex total knee replacement were
promising, but a five year follow up of 43 patients (Journal of
the Royal College of Surgeons of Edinburgh 1997;42:191-8) found
that there had been eight fractures affecting the prosthesis, seven
patients had had dislocated or subluxed patellae, two had had deep
infections, and three had had severe aseptic loosening. Overall, the
high rate of complications and the poor functional results "preclude
its use in current practice."
Computed tomograms and magnetic resonance imaging scans of the
brains of women with anorexia nervosa have consistently shown enlarged
fluid spaces and reduced volumes of both white and grey matter
(Archives of General Psychiatry 1997;54:537-42). When
the women recover, later scans show that the physical changes in the
grey matter and the fluid spaces persist, suggesting that there is an
irreversible component to the changes in the brain associated with
starvation.
In 1884 the American surgeon William Halstead read of the
local anaesthetic effect of cocaine and began experiments with the drug
that led to his becoming addicted (Annals of Surgery
1997;225:445-58). He was treated by being switched to morphine,
but he remained dependent on morphine for most if not all of the
30 years in which he was chief of surgery at Johns Hopkins and the
leading academic surgeon in the United States.
Twenty four volunteers were recruited from London clubs to take
part in a comparison of the effects of methylenedioxymethamphetamine
(ecstasy) and alcohol (Addiction 1997;92:821-33).
Ecstasy elevated the mood and created a sensation of happiness on the
night that it was taken, but the mood became seriously lowered by the
fifth day and some of the volunteers became clinically depressed.
Hangovers from alcohol lasted only into the second day.
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