Intended for healthcare professionals



BMJ 1998; 316 doi: (Published 24 January 1998) Cite this as: BMJ 1998;316:320

Orthopaedic surgeons who are reluctant to perform total hip replacement operations on young patients say that high rates of mechanical failure and wear would inevitably lead to a need for revision operations while the patients were still young. A study of 226 Charnley arthroplasties in 161 patients with an average age of 31 provides evidence to the contrary (Journal of Bone and Joint Surgery [Br] 1997;79:1599-617). The functional results were excellent, and at 25 years the survival of the femoral components was 81% and of the acetabular components 68%.

Whether or not a patient with the carpal tunnel syndrome is sent for electromyography depends largely on whether facilities for the investigation exist in the hospital in which he or she is being seen (British Journal of Rheumatology 1997;36:1328-30). A survey of 81 rheumatologists working in hospitals in Britain found that only half had facilities on site. When electromyography was not readily available patients were more likely to be treated with non-surgical methods, such as injection of steroids or splinting.

For many years oncologists have looked for ways of stimulating the vigour of the immune response that some patients mount against their tumours. According to Cancer Investigation (1997;15:577-87), several trials are currently under way of acute specific immunotherapy using the patient's own tumour cells (or their antigenic components) to provide the stimulus. The most promising results have come in patients with some types of B cell lymphomas in remission after initial treatment.

Jumper's knee is the name given to anterior knee pain associated with tenderness of the patellar tendon near its patellar attachment. Objective evidence of the lesion comes from ultrasound scanning, which shows a characteristic hyperechoic region at the inferior pole of the patella. The disorder is common in people who play soccer or basketball as well as those taking part in actual jumping events (British Journal of Sports Medicine 1997;31:332-6). A survey of 100 athletes with jumper's knee seen in one clinic found that 18 had had to give up their sport for longer than one year. Around one third eventually require surgery.

Women are thought to have a worse prognosis than men after an acute myocardial infarction, and this has been examined carefully in the third international study of infarct survival (ISIS 3). Data on survival during days 0–35 were collected for 9600 women and 26 480 men (New England Journal of Medicine 1998;338:8-14). The odds ratio for death among women as compared with men was 1.73 (95% confidence interval 1.61 to 1.86), but after adjustment for age this fell to 1.20, and further adjustments reduced the difference to 1.14. The conclusion is that sex has at most only a small independent effect on early mortality.

A review of fungal blood cultures in Clinical Infectious Diseases (1997;25:1350-3) has concluded that they are labour intensive, expensive, and of little clinical value. These conclusions came from study of the case notes of 322 patients with AIDS who had had 1162 fungal blood cultures. Only in 15 was a true pathogen identified. Fungi were found much more frequently by serological tests, stains and cultures of tissues and body fluids, and examination of biopsy specimens.

Most women given hormone replacement therapy stop at around the age of 60, though the risk of an osteoporotic fracture of the spine is still low at that age. By the time they are at high risk—at around 80—any benefits from the effects of the therapy on bone have gone. So the sensible approach, say the enthusiasts for bisphosphonates (Archives of Internal Medicine 1997;157:2617-24), is to identify and treat with bisphosphonates the 80 year olds at highest risk (those with low bone density and at least one fracture of a vertebra on radiographic examination of the spine).

And staying with bone, Minerva was somewhat daunted by a review in the American Journal of Medicine (1997;103:427-36) of biochemical markers of bone disease. It listed those in current use—osteocalcin, alkaline and acid phosphatase, various procollagens and collagens, hydroxyproline, and pyridinium cross links—and their appropriateness for different bone diseases. Then came the comforting comment that many of the newcomers have been “imperfectly studied,” so presumably clinicians need not yet believe they are out of touch if some of these markers seem exotic.

For more than a century urological surgeons have used their patients' bowel to replace or reconstruct the bladder, despite its mucosa not being designed to cope with urine. Research workers have recently (Journal of Urology 1998;159:2-3) succeeded in transplanting autologous urothelial cells to provide a tough lining for demucosalised bowel. The concept of cell transplantation for reconstruction has its origins in the use of keratinocytes in the treatment of patients with burns.

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A boy aged 14 came to the accident and emergency department in acute respiratory distress having aspirated the cap of his steroid inhaler for rhinitis (picture posed by volunteer). He had removed the cap with his teeth and had tried to keep it between the teeth while he used the spray, but had sucked it into his lungs. At tracheoscopy the cap was located 4 cm below the vocal cords and was removed. He made an uneventful recovery. We believe that the safety standards for pen tops should apply to the caps of inhalers to protect children who might inhale them.

D J McFerran, senior registrar, V Chitre, senior house officer, P R Prinsley, consultant surgeon, ENT department, Norfolk and Norwich Hospital NR1 3SR

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Cancers need blood vessels in order to grow. They activate quiescent vasculature via an angiogenic switch, which may become activated in the premalignant phase. Treatment aimed at switching off the angioneogenesis has proved successful in mice (Nature Medicine 1998;4:13-4). The tumours did not become drug resistant, probably because the endothelial cells lack the genomic instability of the cancer cells that allows them to develop resistant mutants.

Junior doctors usually learn to suture “on the job” with some supervision from a more senior surgeon. In the department of plastic and reconstructive surgery at the Northern General Hospital in Sheffield they practise their suturing skills using Lyofoam as a skin substitute (Journal of the Royal College of Surgeons of Edinburgh 1997;42:383-5). Those trained in this way were shown to produce superior needlework as assessed by suture tensions and spacing.