Primary angioplasty for acute myocardial infarction gives better
results than thrombolytic treatment, and a group of articles in the
current issue of Heart (1997;78:323-36) presents strong
arguments for immediate angioplasty to be made more widely available.
Patients who should be given priority for angioplasty include those
with cardiogenic shock and those with contraindications to
thrombolytic treatment. As with medical thrombolysis, time is of the
essence.
Data from 10 AIDS reference centres in France looking after 7749
patients have shown that since the introduction of protease inhibitors
and highly active antiretroviral treatment (HAART) the costs of
treatment have risen but expenditure on admission to hospital has
fallen (AIDS 1997;11:F101-5). The cost of the drugs has
risen by around $12 per patient each month, but the total costs of the
health care have fallen by $101 per patient each month.
Outbreaks of Lassa fever continue to occur in Nigeria, and
a recent study there has found that 12.3% of 552 health workers tested
had antibodies to the Lassa virus (Transactions of the Royal
Society of Tropical Medicine and Hygiene 1997;91:379-81). Rates
were highest in locations where there had been recent outbreaks.
The authors comment that even simple barrier techniques are little used
in primary and secondary health centres.
Cocaine is dangerous stuff: the Journal of
Neurology, Neurosurgery and Psychiatry
(1997;63:531-3) describes two young men who had spinal
ischaemic infarcts shortly after injecting the drug and a third case of
a spinal transient ischaemic attack. One patient was left with
permanent tetraparesis. Cocaine should be included among the
possible causes of acute non-traumatic myelopathy, especially in
young patients.
Telephone calls to accident and emergency departments asking for
advice have become much more common recently; a study at one department
in London recorded 597 calls in three months (Quality in Health
Care 1997;6:140-5). Questioning of the callers found high
levels of satisfaction, but about one fifth were dissatisfied in some
ways. The staff who answer these calls need further training, the
report concludes, both to improve their telephone skills and to ensure
that the advice given is reliable and consistent.
A pilot study of the use of induced moderate hypothermia in
patients who remained unconscious after recovery from a cardiac arrest
is reported in Annals of Emergency Medicine
1997;30:146-53). Eleven of the 22 patients treated by cooling
had a good outcome as compared with only three of 22 historical
controls. The authors claim that these data warrant the setting up of a
formal controlled trial.
Minerva likes clinical rarities. Metastatic cancer deposits in
the appendix is one example. A case report in the American
Surgeon (1997;63:778-80) describes a man aged 54 who had been
treated for lung cancer and later developed pain in the right lower
quadrant and a fever. He was thought to have appendicitis, but at
operation the appendix was found to be infiltrated with cells
histologically similar to his lung primary.
The stents used to maintain patency of biological passageways
such as the coronary arteries or the oesophagus probably take their
name from an English dentist born in 1807 (European Heart
Journal 1997;18:1536-47). Stent and his dentist sons used a
special apparatus to support poorly aligned teeth. The term was first
used with its current meaning in 1954.
The selective serotonin reuptake inhibitor sertraline proved
superior to placebo in a randomised trial of treatment for women with
premenstrual dysphoric disorder (Journal of the American Medical
Association 1997;278:983-8). This is the currently accepted
term for the psychological features of the premenstrual syndrome,
including depressed mood, mood swings, and anxiety. The proportion of
patients who were much improved when taking sertraline was 62% - but
34% were much improved when taking placebo.
Do sexually transmitted diseases such as gonorrhoea and
chlamydial urethritis make men infertile? A review article in
Fertility and Sterility (1997;68:205-13) says that the
link between the infections and epididymo-orchitis provides a plausible
mechanism, but the epidemiological evidence is "inconsistent." Once
again, more research is needed.
Further evidence that Alzheimer's disease is more common
in people with low educational attainments has come from a study
in the Netherlands (Journal of Clinical Epidemiology
1997;50:1025-33). Earlier research with this result has
been criticised because the tests used might have been easier for
people with better educations. The tests used in this study were said
to be free of educational bias. Why better education should protect
against dementia is still being debated.
Among the accepted AIDS defining disorders are Kaposi's
sarcoma, carcinoma of the cervix, and several types of lymphoma. Many
clinicians believe that some other tumours may be more common in
patients with HIV infection, and a report in the Mayo Clinic
Proceedings (1997;72:761-4) suggests that breast cancer (in
both men and women) may be among these. It should at least be
considered in the differential diagnosis of a mass in the axilla.
How should the clinician decide whether a patient has ulcerative
colitis or Crohn's colitis? A review in the American
Journal of Gastroenterology (1997;92:1247-51)
concludes that most patients with ulcerative colitis have disease that
begins in the rectum and spreads proximally in a contiguous fashion,
but some have patchy disease. The final decision in such cases has to
be based on "clinical judgment."
Splenectomy has been used for many years as a treatment for some
of the complications of chronic lymphocytic leukaemia such as
autoimmune haemolytic anaemia and thrombocytopenia as well as for
symptomatic splenomegaly. The evidence for benefit is, however, only
anecdotal. An observational study at the University of Texas
(Journal of the American College of Surgeons
1997;185:237-43) found that the operation had been useful in
patients who were anaemic or thrombocytopenic, but (as is so often the
case) the authors recommended more research.
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