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 Early detection of recurrence of malignant melanoma gives a survival
advantage, so patients who have had "thick" melanomas removed
from their skin are followed up closely. A study in Bristol of
244 patients (British Journal of Plastic Surgery 1997;50:349-53) found that two fifths of the treatable recurrences
were diagnosed in the first year after surgery. The report suggests
that patients should be seen every two months for the first year,
every three months in the second, and gradually less often, until
after 10 years the follow up can be done in general practice.
The gall bladder is perforated and stones are spilled into the
peritoneal cavity more frequently during laparoscopic cholecystectomy
than during open surgery, says a report in the Canadian Journal of Surgery (1997;40:300-4). Stones left behind in the abdomen usually cause
no problems, but they may lead to serious complications requiring
open surgery. Furthermore, a stone left behind is a potential
nidus for a legal action at a later date.
Treatment of acute myocardial infarction with glucose, insulin,
and potassium was introduced in 1962 with the aim of promoting
electrical stability for the myocardium. Controlled trials gave
conflicting results, but a systematic review of the trials with
acceptable randomisation (Circulation 1997;96:1152-6) found that the treatment led to a 28% fall in
mortality. The time has come, says Circulation, for a large prospective trial.
Over 25 years ago islet cell transplantation was found to cure
diabetes in rats and mice, but it remains a rare experimental
treatment in humans. A review in Diabetes (1997;46:1247-56) says that of 270 patients with insulin dependent
diabetes treated by islet cell transplantation, only 14 were independent
of insulin one year later. Nevertheless, the procedure remains
the best prospect for cure, and patient groups believe that more
money should be provided for research.
Hypothyroidism in elderly patients may sometimes present with
intestinal disturbances, including atony, distension, pseudo-obstruction,
and even perforation. A paper in Diseases of the Colon and Rectum (1997;40:859-61) describes six patients who presented in this
way; four had laparotomies before the diagnosis was made. Surgeons
need to remember the possibility of thyroid deficiency in patients
with refractory or unexplained constipation.
Measurement of the erythrocyte sedimentation rate is an antique
test which should be replaced by measurement of the plasma viscosity,
says a letter in the New Zealand Medical Journal (1997;110:322). The viscosity test has none of the technical difficulties
of measurement of the erythrocyte sedimentation rate, is highly
reproducible, and has a narrow, well defined clinical range. Furthermore,
the plasma may be stored for up to one week before the test is
done, and that means that specimens may be sent by post.
Patients who have an organ transplant risk developing post-transplantation
lymphoproliferative disease, which affects 2-5% of patients, with
its peak incidence in the first year after operation. A review
in the Quarterly Journal of Medicine (1997;90:497-503) concludes that the treatment currently available
- reduction in immunosuppression and chemotherapy - is of limited
value but that some encouraging results have been reported for
attempts at immunotherapy directed at the Epstein-Barr virus.
Motor restlessness or akathisia is an under-recognised disorder
usually associated with long term treatment with neuroleptic or
antidepressant drugs (Postgraduate Medical Journal 1997;73:529-30). The condition may sometimes be misdiagnosed
as the restless legs syndrome, but akathisia ceases during sleep.
Withdrawal of the drug responsible usually leads to recovery.
Finnish women hairdressers experienced a doubling in their prevalence
of asthma between 1980 and 1995 (Journal of Occupational and Environmental Medicine 1997;39:534-9). In both those years the relative risk in hairdressers
was twice that in shopworkers, suggesting that occupational exposure
plays a part and warrants further investigation.
Most Western countries have seen death rates from myocardial infarction
fall in the past 20 years. A report from Canada in the Journal of Clinical Epidemiology (1997;50:787-91) says that half the fall can be explained by
a decline in the attack rate of acute myocardial infarction: between
1984 and 1993 the rate fell from 221 to 179/100 000. The case
fatality fell slightly. So changes in lifestyle may probably take
more of the credit than advances in medical treatment.
The second patient in the world given a prosthetic heart valve
developed endocarditis 23 years later - graphic evidence that
infection may occasionally be much delayed. More often infection
develops in the first year after surgery (Journal of Infection 1997;35:1-6). There is still no consensus on whether prophylactic
antibiotics should be prescribed and, if so, which ones and for
how long. Good oral hygiene does reduce the risk.
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