MinervaBMJ 1997; 315 doi: https://doi.org/10.1136/bmj.315.7110.756 (Published 20 September 1997) Cite this as: BMJ 1997;315:756
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.
A woman aged 24 was stabbed in the head. Initially she was irritable, moving all limbs, with equal and reactive pupils. She was anaesthetised immediately on arrival at our intensive care unit to prevent her movements causing further damage. A craniectomy and removal of the knife were uneventful. She was discharged home two weeks after surgery with a left homonymous hemianopia, an optokinetic nystagmus to the right (localising the lesion to the right parietal cortex), substantial anxiety, and no other neurological abnormality.
Alister Hart, senior house officer, Adrian Casey, senior registrar, National Hospital for Neurology and Neurosurgery, Queen Square, London WC1.
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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.