ARTICLE TITLE: Preemptive epidural analgesia and recovery from
radical prostatectomy: a randomized controlled trial [see
comments]
COMMENTS: Comment in: JAMA 1998 Apr 8; 279(14):1114-5
ARTICLE SOURCE: JAMA (United States), Apr 8 1998, 279(14)
p1076-82
AUTHOR(S): Gottschalk A; Smith DS; Jobes DR; Kennedy SK; Lally SE;
Noble VE; Grugan KF; Seifert HA; Cheung A; Malkowicz SB; Gutsche BB;
Wein AJ
AUTHOR'S ADDRESS: Department of Anesthesia, School of Medicine,
University of Pennsylvania, Philadelphia 19104, USA.
ag@network3.entropy.upenn.edu.
ABSTRACT: CONTEXT: Preemptive analgesia can decrease the
sensitization of the central nervous system that would ordinarily
amplify subsequent nociceptive input, but a clear demonstration of
its clinical efficacy is necessary for it to become a routine
component of acute pain therapy. OBJECTIVE: To determine the impact
of preemptive epidural analgesia on postoperative pain and other
clinically important outcome variables after radical retropubic
prostatectomy. DESIGN AND SETTING: A block randomized double-blind
clinical trial lasting 20 months at a single academic medical center.
PATIENTS: A total of 100 generally healthy and neurologically intact
patients scheduled for radical retropubic prostatectomy for the
treatment of prostate cancer in whom an epidural catheter for
treating postoperative pain was to be placed prior to the induction
of general anesthesia. INTERVENTIONS: Epidural bupivacaine, epidural
fentanyl, or no epidural drug was administered prior to induction of
anesthesia and throughout the entire operation, followed by
aggressive postoperative epidural analgesia for all patients. MAIN
OUTCOME MEASURES: Daily pain scores during hospitalization and pain
scores obtained 3.5, 5.5, and 9.5 weeks after hospital discharge.
RESULTS: The patients who received epidural fentanyl or bupivacaine
prior to surgical incision (preemptive analgesia) experienced 33%
less pain while hospitalized (P=.007). Pain scores in those receiving
preemptive analgesia were significantly lower at 9.5 weeks (P=.02),
but were not significantly different at 3.5 or 5.5 weeks. At 9.5
weeks, 32 (86%) of 37 patients receiving preemptive analgesia were
pain-free compared with 9 (47%) of 19 control patients (P=.004).
Patients receiving preemptive analgesia were more active 3.5 weeks
after surgery (P=.01), but not at 5.5 or 9.5 weeks. CONCLUSIONS: Even
in the presence of aggressive postoperative pain management,
preemptive epidural analgesia significantly decreases postoperative
pain during hospitalization and long after discharge, and is
associated with increased activity levels after discharge.
ARTICLE TITLE: Why review articles on the health effects of
passive smoking reach different conclusions.
ARTICLE SOURCE: JAMA (United States), May 20 1998, 279(19)
p1566-70
AUTHOR(S): Barnes DE; Bero LA
AUTHOR'S ADDRESS: Department of Public Health Biology and
Epidemiology, School of Public Health, University of California,
Berkeley, USA.
CONCLUSIONS: The conclusions of review articles are strongly
associated with the affiliations of their authors. Authors of review
articles should disclose potential financial conflicts of interest,
and readers of review articles should consider authors' affiliations
when deciding how to judge an article's conclusions.
ARTICLE TITLE: Are beta-blockers efficacious as first-line therapy
for hypertension in the elderly? A systematic review.
ARTICLE SOURCE: JAMA (United States), Jun 17 1998, 279(23)
p1903-7
AUTHOR(S): Messerli FH; Grossman E; Goldbourt U
AUTHOR'S ADDRESS: Department of Internal Medicine, Ochsner Clinic and
Alton Ochsner Medical Foundation, New Orleans, LA 70121, USA.
Fmesserli@aol.com.
CONCLUSIONS: In contrast to diuretics, which remain the standard
first-line therapy, beta-blockers, until proven otherwise, should no
longer be considered appropriate first-line therapy of uncomplicated
hypertension in the elderly hypertensive patient.
ARTICLE TITLE: The case for "presumed consent" in organ donation.
International Forum for Transplant Ethics.
ARTICLE SOURCE: Lancet (England), May 30 1998, 351(9116) p1650-2
AUTHOR(S): Kennedy I; Sells RA; Daar AS; Guttmann RD; Hoffenberg R;
Lock M; Radcliffe-Richards J; Tilney N
AUTHOR'S ADDRESS: School of Public Policy, University College, London
University, UK.
ARTICLE TITLE: Rugby and spinal injury: what can be done?
[editorial; comment]
COMMENTS: Comment on: Med J Aust 1998 Apr 20; 168(8):379-81
ARTICLE SOURCE: Med J Aust (Australia), Apr 20 1998, 168(8)
p372-3
AUTHOR(S): Yeo JD
ARTICLE TITLE: Primary pulmonary hypertension: new reasons for
optimism? [editorial]
ARTICLE SOURCE: Med J Aust (Australia), Apr 6 1998, 168(7) p316-7
AUTHOR(S): Williams TJ
ARTICLE TITLE: The death of a healthy volunteer in a human
research project: implications for Australian clinical research.
ARTICLE SOURCE: Med J Aust (Australia), May 4 1998, 168(9)
p449-51
AUTHOR(S): Day RO; Chalmers DR; Williams KM; Campbell TJ
AUTHOR'S ADDRESS: Clinical Pharmacology, St Vincent's Hospital,
Sydney, NSW. R.Day@unsw.edu.au.
ABSTRACT: A healthy 19-year-old United States college student
volunteer in a clinical research program underwent a bronchoscopy and
died as a result of acute lignocaine toxicity. The major contributing
factor in the tragedy was that the research protocol failed to
specify an upper dose limit for lignocaine spray, although previous
versions of the protocol had done so. We look at the implications of
this case for Australian institutional ethics committees.
ARTICLE TITLE: Asthma and other atopic diseases in Australian
children. Australian arm of the International Study of Asthma and
Allergy in Childhood.
ARTICLE SOURCE: Med J Aust (Australia), May 4 1998, 168(9) p434-8
AUTHOR(S): Robertson CF; Dalton MF; Peat JK; Haby MM; Bauman A;
Kennedy JD; Landau LI
AUTHOR'S ADDRESS: Department of Thoracic Medicine, Royal Children's
Hospital, Melbourne. cfrob@cryptic.rch.unimelb.edu.au.
ABSTRACT: OBJECTIVE: To determine the prevalence of asthma, eczema
and allergic rhinitis in Australian schoolchildren using the protocol
of the International Study of Asthma and Allergy in Childhood
(ISAAC). DESIGN: Questionnaire-based survey. SETTING: Melbourne,
Sydney, Adelaide (in winter-spring, 1993) and Perth (in
winter-spring, 1994). SUBJECTS: All children in school years 1 and 2
(ages 6-7 years) or in year 8 (ages 13-14 years), attending a random
sample of 272 schools, stratified by age and city. MAIN OUTCOME
MEASURES: Parent-reported (for 6-7 year olds) or self-reported (for
13-14 year olds) symptoms of atopic disease in the previous 12
months, or ever; treatment of asthma; and country of birth. RESULTS:
10,914 questionnaires were completed for 6-7 year olds and 12,280 for
13-14 year olds (84% and 94% response rates, respectively).
Prevalence of wheeze in the past 12 months was 24.6% for the 6-7 year
olds and 29.4% for the 13-14 year olds, and, among 6-7 year olds, was
significantly higher in boys (27.4%) than girls (21.7%). Children
born in Australia were more likely to report current wheeze than
those born elsewhere (6-7 year olds: odds ratio [OR], 1.82;
95% confidence interval [CI] 1.55-2.15; and 13-14 year olds:
OR, 1.88; 95% CI, 1.68-2.11). Prevalences of current eczema and
allergic rhinitis were 10.9% and 12.0%, respectively, for the 6-7
year olds, and 9.7% and 19.6%, respectively, for the 13-14 year olds.
Asthma, eczema and rhinitis coexisted in 1.8% of 6-7 year olds and
2.8% of 13-14 year olds. CONCLUSION: This study provides evidence
that asthma prevalence in Australian schoolchildren is continuing to
increase and is higher among Australian-born children than among
those born elsewhere. Asthma, eczema and allergic rhinitis coexist to
a lesser extent than expected. These results form the basis for
future Australian and international comparisons.
ARTICLE TITLE: An epidemic of renal failure among Australian
Aboriginals [see comments]
COMMENTS: Comment in: Med J Aust 1998 Jun 1; 168(11):532-3
ARTICLE SOURCE: Med J Aust (Australia), Jun 1 1998, 168(11)
p537-41
AUTHOR(S): Spencer JL; Silva DT; Snelling P; Hoy WE
AUTHOR'S ADDRESS: Menzies School of Health Research, Casuarina,
NT.
CONCLUSIONS: The predicted doubling of ESRD incidence among
Aboriginal people by the year 2000 will add an enormous burden to
limited resources. Risk factors for renal disease underlie all the
excess morbidity and mortality in NT Aboriginal adults, and arise out
of accelerated lifestyle changes and socioeconomic disadvantage.
Better living conditions and education, robust and integrated primary
healthcare programs, and systematic screening for early renal disease
and treatment of those with established disease are all matters of
urgency.
ARTICLE TITLE: Reexploration for hemorrhage following coronary
artery bypass grafting: incidence and risk factors. Northern New
England Cardiovascular Disease Study Group.
ARTICLE SOURCE: Arch Surg (United States), Apr 1998, 133(4)
p442-7
AUTHOR(S): Dacey LJ; Munoz JJ; Baribeau YR; Johnson ER; Lahey SJ;
Leavitt BJ; Quinn RD; Nugent WC; Birkmeyer JD; O'Connor GT
AUTHOR'S ADDRESS: Department of Surgery, Dartmouth-Hitchcock Medical
Center, Lebanon, NH, USA. lawrence.j.dacey@hitchcock.org.
ABSTRACT: OBJECTIVE: To assess mortality and risk factors associated
with reexploration for hemorrhage in patients undergoing coronary
artery bypass grafting (CABG). DESIGN: Regional cohort study. Patient
characteristics, treatment variables, and outcome measures were
collected prospectively. SETTING: All 5 centers performing cardiac
surgery in Maine, New Hampshire, and Vermont. PATIENTS: A consecutive
cohort of 8586 patients undergoing isolated CABG between 1992 and
1995. MAIN OUTCOME MEASURES: Postoperative hemorrhage leading to
reexploration, in-hospital mortality, and length of stay. RESULTS: A
total of 305 patients (3.6%) underwent reexploration for bleeding. In
these patients, in-hospital mortality was nearly 3 times higher (9.5%
vs 3.3% for patients not requiring reoperation, P .001) and average
length of stay from surgery to discharge was significantly longer
(14.5 days vs 8.6 days, P .001). High rates of reexploration for
hemorrhage were observed in patients with prolonged ( 150 minutes)
cardiopulmonary bypass (39 [11.1%] of 351) and in those
requiring an intra-aortic balloon pump intraoperatively (12
[8%] of 139). In multivariate analysis, older age, smaller
body surface area, prolonged cardiopulmonary bypass, and number of
distal anastomoses were associated with increased bleeding risks. The
use of thrombolytic therapy within 48 hours of surgery was weakly but
not significantly associated with the need for reexploration. Factors
not significantly associated with reexploration included patient sex,
preoperative ejection fraction, surgical priority, history of liver
disease, myocardial infarction, prior CABG, renal failure, and
diabetes mellitus. CONCLUSIONS: Hemorrhage requiring reexploration
after CABG is associated with markedly increased mortality and length
of stay. Patients predicted to have increased risks of bleeding may
benefit from prophylactic use of aprotinin, aminocaproic acid, or
other agents shown to reduce hemorrhage.
ARTICLE TITLE: Preemptive pain control in patients having
laparoscopic hernia repair: a comparison of ketorolac and
ibuprofen.
ARTICLE SOURCE: Arch Surg (United States), Apr 1998, 133(4)
p432-7
AUTHOR(S): Mixter CG 3rd; Meeker LD; Gavin TJ
AUTHOR'S ADDRESS: Department of Surgery, Exeter Hospital, NH,
USA.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED
CONTROLLED TRIAL
ABSTRACT: OBJECTIVES: To determine if nonsteroidal anti-inflammatory
drugs provide adequate pain control for patients having laparoscopic
hernia repair and to compare the effectiveness of ketorolac
tromethamine with ibuprofen in reducing postoperative laparoscopic
hernia pain. DESIGN AND SETTING: Prospective double-blind randomized
study at a 100-bed community hospital. PATIENTS: Seventy patients
ranging in age from 16 to 83 years scheduled for elective
laparoscopic inguinal hernia repair. INTERVENTIONS: Patients
undergoing laparoscopic hernia repair were enrolled in a double-blind
randomized study to compare the 2 treatments. Group 1 received a
placebo capsule 1 hour before surgery and ketorolac tromethamine, 60
mg intravenously, at the time of trocar insertion. Group 2 received
ibuprofen, 800 mg an hour before surgery, and isotonic sodium
chloride solution, 2 mL intravenously, at the time of trocar
insertion. In addition, all patients received local infiltration of
30 mL of bupivacaine hydrochloride into their trocar sites. All
patients were discharged within 5 hours of the operation and were
instructed to take 400 mg of ibuprofen orally every 4 hours for 24
hours whether or not they were experiencing pain. A 24-hour supply of
ibuprofen was provided to all study patients. Pain was assessed using
the Visual Analog Pain Scale with a maximum pain rating of 100.
Assessments were done at the time of and 18 hours after discharge.
MAIN OUTCOME MEASURE: Postoperative pain 18 and 24 hours after
discharge was assessed using a standardized questionnaire in a
telephone interview by a registered nurse from the Outpatient
Surgical Unit. RESULTS: There was no significant difference in the
level of pain experienced by 35 patients who received ketorolac
intravenously and 35 who received ibuprofen orally. There was no
significant difference between the 2 treatment groups in the amount
of pain experienced at discharge and 18 hours after discharge.
CONCLUSIONS: Pain relief from ibuprofen, 800 mg, administered orally
an hour before laparoscopic hernia repair was not statistically
different from that obtained with intravenous ketorolac, 60 mg,
administered intraoperatively when comparing the hospital discharge
pain score and the mean and highest pain scores 18 hours after
discharge. Ibuprofen offers equivalent pain control at a lower cost
and reduced potential for adverse drug events compared with
intravenous ketorolac in patients having laparoscopic hernia repair.
No patient required narcotic supplementation, and pain control was
judged satisfactory by all the patients.
ARTICLE TITLE: A randomized, prospective, blinded comparison of
postoperative pain, metabolic response, and perceived health after
laparoscopic and small incision cholecystectomy.
ARTICLE SOURCE: Surgery (United States), May 1998, 123(5) p485-95
AUTHOR(S): Squirrell DM; Majeed AW; Troy G; Peacock JE; Nicholl JP;
Johnson AG
AUTHOR'S ADDRESS: Department of Surgical and Anaesthetic Sciences,
University of Sheffield, U.K.
ABSTRACT: BACKGROUND: We have previously shown that in a randomized
comparison of laparoscopic (LC) versus small incision (SC)
cholecystectomy, postoperative hospital stay is comparable. This
randomized prospective study compares the postoperative pain,
analgesic and antiemetic consumption, perceived health, and metabolic
and respiratory responses after these two procedures. METHODS: Two
hundred patients were recruited; postoperative stay, pain scores,
analgesic and antiemetic consumption were recorded. Nottingham Health
Profile questionnaires were completed by a subgroup of 100 patients,
and the metabolic and respiratory responses were also compared in a
further subgroup of 20 patients. RESULTS: Pain scores in both groups
were low. LC, however, was associated with lower postoperative pain
scores and analgesic requirements compared with SC, but the
antiemetic requirements were greater after LC. The duration of
hospital stay and the perceived health after operation were the same
in both groups, and both procedures were associated with a similar
reduction of respiratory function. Twenty-four hours after operation
the inflammatory (C-reactive protein, CRP) response to LC (22 +/- 20
mg/L) was significantly lower than after SC (68 +/- 30 mg/L), but the
neuroendocrine (cortisol) response was similar (LC, 475 +/- 335
nmol/L, compared with SC, 710 +/- 410 nmol/L). Independent of the
technique used, the duration of postoperative hospital stay
correlated significantly with the magnitude of both the 24-hour
postoperative cortisol and CRP responses (cortisol: rs = 0.678, p
0.001; CRP: rs = 0.566, p = 0.011). CONCLUSIONS: LC appears to be
associated with less tissue destruction and pain than SC, but this
did not confer any advantage in the degree of postoperative
respiratory impairment, length of hospital stay, or postoperative
perceived health. The neuroendocrine component of the metabolic
response evoked by each procedure was similar and had a significant
correlation to patient's postoperative hospital stay. This finding
may explain the similar postoperative recovery after LC and SC.
ARTICLE TITLE: The life and death of Professor Alexander P.
Borodin: surgeon, chemist, and great musician.
ARTICLE SOURCE: Surgery (United States), Jun 1998, 126(6) p606-16
AUTHOR(S): Konstantinov IE
ARTICLE TITLE: Endoluminal abdominal aortic aneurysm surgery.
ARTICLE SOURCE: Br J Surg (England), Apr 1998, 85(4) p435-43
AUTHOR(S): Woodburn KR; May J; White GH
AUTHOR'S ADDRESS: Department of Vascular Surgery, Royal Prince Alfred
Hospital, University of Sydney, Australia.
ABSTRACT: BACKGROUND: The development of devices designed for the
endoluminal repair of abdominal aortic aneurysm has led to the
emergence of new endovascular techniques. METHODS: Articles and case
reports obtained from a Medline search of the English language
literature from 1989 to 1997 are reviewed. This search was carried
out using the MeSH heading 'aortic aneurysm, abdominal' and the
keywords 'endovascular' and 'endoluminal'. RESULTS: Reported
mortality and complication rates for endoluminal aneurysm repair are
similar to those following conventional repair, with the exception of
continued perfusion of the aneurysm sac which remains a major problem
following endoluminal repair. CONCLUSION: Successful endoluminal
aneurysm exclusion is associated with reduced aneurysm diameter.
However, longer term results of endoluminal repair, in particular of
sealed endoleaks, are required before randomized controlled trials of
endoluminal versus conventional repair can be undertaken.
ARTICLE TITLE: Effect of graft reperfusion on intracellular
calcium levels in mononuclear leucocytes during human orthotopic
liver transplantation.
ARTICLE SOURCE: Br J Surg (England), May 1998, 85(5) p673-6
AUTHOR(S): Enright SM; Srinivasa R; Bellamy MC
AUTHOR'S ADDRESS: Department of Anaesthesia, St James's University
Hospital, Leeds, UK.
CONCLUSION: There was a significant increase in circulating monocyte
membrane permeability for calcium and cytosolic calcium concentration
following reperfusion in human OLT. This was independent of
extracellular calcium concentration. These results are consistent
with WBC activation by reperfusion and could be implicated in the
systemic reperfusion syndrome
ARTICLE TITLE: Effect of dopamine on renal function after
arteriography in patients with pre-existing renal insufficiency.
ARTICLE SOURCE: Am Surg (United States), May 1998, 64(5) p432-6
AUTHOR(S): Hans SS; Hans BA; Dhillon R; Dmuchowski C; Glover J
AUTHOR'S ADDRESS: Department of Surgery, Macomb Hospital Center,
Warren, Michigan, USA.
ABSTRACT: Contrast media-induced nephropathy is one of the leading
causes of hospital-acquired renal failure, occurring most frequently
in patients with pre-existing renal insufficiency. We prospectively
studied 55 patients with chronic renal insufficiency (serum
creatinine concentration 1.4 to 3.5 mg/dl) who underwent abdominal
aortography and arteriography of the lower extremities. The patients
were randomized into two groups. Group 1, 28 patients, received
dopamine 2.5 mcg/kg beginning 1 hour before arteriography and
continuing for 12 hours. Group 2 received an equal volume of saline
for the same period of time. Serum creatinine and 12-hour creatinine
clearance were measured before arteriography and for 4 consecutive
days afterward. Acute contrast-induced decrease in renal function was
defined as increase in the baseline serum creatinine concentration or
= 0.5 mg/dl. On day 1 postarteriography the serum creatinine
increased from baseline .193 mg/dl for controls while the dopamine
group decreased slightly from baseline .018 mg/dl (p = 0.002).
Excepting day 1 postarteriography, there was no statistical
difference between groups, and serum levels for both groups increased
linearly from baseline across time (dopamine p = 0.028, control p =
0.025). In patients with pre-arteriography baseline serum levels
greater than or equal to 2.0 mg/dl, however, the increase in serum
creatinine from baseline levels was consistently and significantly
greater in the control group through the fourth day (0.012 or = p or
= 0.049). Creatinine clearance did not change significantly from
baseline after arteriography in the dopamine group (baseline versus
days 1 through 4, 0.238 or = p or = 0.968); however, the control
group showed a significant linear decrease in creatinine clearance
from baseline through the fourth day after arteriography (p = 0.016).
Dopamine infusion prevented a rise in serum creatinine 24 hours after
angiography in patients with pre-existing renal insufficiency, and
protected against contrast-induced decrease in renal function in
patients whose baseline serum creatinine was or = 2.0 mg/dl.
ARTICLE TITLE: Task performance in endoscopic surgery is
influenced by location of the image display.
ARTICLE SOURCE: Ann Surg (United States), Apr 1998, 227(4) p481-4
AUTHOR(S): Hanna GB; Shimi SM; Cuschieri A
AUTHOR'S ADDRESS: Department of Surgery, Ninewells Hospital &
Medical School, University of Dundee, Tayside, Scotland.
CONCLUSIONS: Task performance improves when the image display is
placed in front of the operator, at a level below the head and close
to the hands.
ARTICLE TITLE: "Renal dose" dopamine in surgical patients: dogma
or science?
ARTICLE SOURCE: Ann Surg (United States), Apr 1998, 227(4) p470-3
AUTHOR(S): Perdue PW; Balser JR; Lipsett PA; Breslow MJ
AUTHOR'S ADDRESS: Department of Surgery, Johns Hopkins University
School of Medicine, Baltimore, Maryland, USA.
ABSTRACT: OBJECTIVE: "Renal dose" dopamine is widely used in the
perioperative period to provide renal protection. A comprehensive
review of the literature was performed to determine whether dopamine
does in fact confer protection on the kidneys of surgical patients.
SUMMARY BACKGROUND DATA: Studies in healthy animals and human
volunteers reveal that dopamine causes diuresis and natriuresis, as
well as some degree of renal vasodilatation. RESULTS: Studies of the
perioperative use of dopamine fail to demonstrate any benefit of
dopamine in preventing renal failure. Studies in congestive heart
failure, critical illness, and sepsis also fail to show any benefit
of dopamine other than diuresis. Further, dopamine administration is
not completely without risk, because of dopamine's catecholamine and
neuroendocrine functions. CONCLUSIONS: Routine use of prophylactic
"renal dose" dopamine in surgical patients is not recommended.
ARTICLE TITLE: Trauma service cost: the real story.
ARTICLE SOURCE: Ann Surg (United States), May 1998, 227(5) p720-4;
discussion 724-5
AUTHOR(S): Taheri PA; Wahl WL; Butz DA; Iteld LH; Michaels AJ;
Griffes LC; Bishop G; Greenfield LJ
AUTHOR'S ADDRESS: Department of Surgery, University of Michigan
Health System, Ann Arbor, USA.
CONCLUSIONS: Identification of the true cost centers and directed
attending surgeon involvement are essential to the development and
implementation of a successful cost-reduction process.
ARTICLE TITLE: A national survey of physician-assisted suicide and
euthanasia in the United States.
ARTICLE SOURCE: N Engl J Med (United States), Apr 23 1998, 338(17)
p1193-201
AUTHOR(S): Meier DE; Emmons CA; Wallenstein S; Quill T; Morrison RS;
Cassel CK
AUTHOR'S ADDRESS: Department of Geriatrics and Adult Development,
Mount Sinai School of Medicine, New York, NY 10029, USA.
CONCLUSIONS: A substantial proportion of physicians in the United
States report that they receive requests for physician-assisted
suicide and euthanasia, and about 7 percent of those who responded to
our survey have complied with such requests at least once.
ARTICLE TITLE: Ten-year risk of false positive screening
mammograms and clinical breast examinations [see
comments]
COMMENTS: Comment in: N Engl J Med 1998 Apr 16; 338(16):1145-6
ARTICLE SOURCE: N Engl J Med (United States), Apr 16 1998, 338(16)
p1089-96
AUTHOR(S): Elmore JG; Barton MB; Moceri VM; Polk S; Arena PJ;
Fletcher SW
AUTHOR'S ADDRESS: Department of Medicine, University of Washington
School of Medicine, Seattle 98195-6429, USA.
CONCLUSIONS: Over 10 years, one third of women screened had an
abnormal test result that required additional evaluation, even though
no breast cancer was present. Techniques are needed to decrease false
positive results while maintaining high sensitivity. Physicians
should educate women about the risk of a false positive result from a
screening test for breast cancer.
ARTICLE TITLE: Should we accept mediocrity?
ARTICLE SOURCE: N Engl J Med (United States), Apr 9 1998, 338(15)
p1067-9
AUTHOR(S): Manian FA
AUTHOR'S ADDRESS: Infectious Diseases Consultants, St. Louis, MO
63141, USA.
MAJOR SUBJECT HEADING(S): Managed Care Programs [standards];
Patient Care [standards]; Quality of Health Care
MINOR SUBJECT HEADING(S): Clinical Competence; Cost Control;
Insurance, Health, Reimbursement; Managed Care Programs
[organization & administration]; Personnel Staffing and
Scheduling; Quality of Health Care [economics]
[organization & administration] [trends]
ARTICLE TITLE: Acid-base disorders [letters]
ARTICLE SOURCE: N Engl J Med (United States), May 28 1998, 338(22)
p1626-7; discussion 1628-9
AUTHOR(S): Marik P; Varon J etc
ARTICLE TITLE: The treatment of unrelated disorders in patients
with chronic medical diseases [see comments]
COMMENTS: Comment in: N Engl J Med 1998 May 21; 338(21):1541-2
ARTICLE SOURCE: N Engl J Med (United States), May 21 1998, 338(21)
p1516-20
AUTHOR(S): Redelmeier DA; Tan SH; Booth GL
AUTHOR'S ADDRESS: Department of Medicine, University of Toronto,
Sunnybrook Health Science Centre, ON, Canada.
CONCLUSIONS: In patients 65 or older who have chronic medical
diseases and who receive prescription medications free of charge,
unrelated disorders are undertreated. Clinicians caring for patients
with chronic diseases should remain alert to other disorders and
minimize the number of missed opportunities for treating them.
ARTICLE TITLE: Patients with multiple chronic conditions--how many
medications are enough? [editorial; comment]
COMMENTS: Comment on: N Engl J Med 1998 May 21; 338(21):1516-20
ARTICLE SOURCE: N Engl J Med (United States), May 21 1998, 338(21)
p1541-2
AUTHOR(S): Steinbrook R
ARTICLE TITLE: Alcohol consumption and mortality in U.S. adults
[letter]
ARTICLE SOURCE: N Engl J Med (United States), May 7 1998, 338(19)
p1385; discussion 1385-6
AUTHOR(S): Urbach DR; Bell CM
ARTICLE TITLE: Rating the appropriateness of coronary
angiography--do practicing physicians agree with an expert panel and
with each other? [see comments]
COMMENTS: Comment in: N Engl J Med 1998 Jun 25; 338(26):1918-20
ARTICLE SOURCE: N Engl J Med (United States), Jun 25 1998, 338(26)
p1896-904
AUTHOR(S): Ayanian JZ; Landrum MB; Normand SL; Guadagnoli E; McNeil
BJ
AUTHOR'S ADDRESS: Department of Medicine, Brigham and Women's
Hospital and Harvard Medical School, Boston, MA 02115, USA.
ABSTRACT: BACKGROUND: Evaluations of the appropriateness of medical
care are important to monitor the quality of care and to contain
costs and enhance safety by reducing inappropriate care. Experts'
views are usually incorporated into evaluations of appropriateness.
However, practicing physicians may not concur with these views, and
physicians' clinical backgrounds may influence their beliefs.
METHODS: We asked 1058 internists, family practitioners, and
cardiologists in California, Florida, New York, Pennsylvania, and
Texas to rate the appropriateness of coronary angiography after acute
myocardial infarction for 20 common indications. Nine clinical
experts also rated these indications using an established consensus
method. RESULTS: For 17 of the 20 indications, median ratings of
surveyed physicians and the expert panel agreed within 1 unit on a
9-unit scale. Patients' older age had a negative effect on ratings by
the expert panel but not on ratings by surveyed physicians. In
multivariable analyses of surveyed physicians, cardiologists rated
angiography as significantly more appropriate than did primary care
physicians for complicated indications, and for uncomplicated
indications cardiologists who performed invasive procedures gave
higher appropriateness ratings for angiography than did cardiologists
who did not perform such procedures and primary care physicians. For
uncomplicated indications, physicians from hospitals providing
coronary angioplasty and bypass surgery rated angiography as more
appropriate than physicians from other hospitals. Physicians from New
York and those employed by health maintenance organizations rated
angiography as less appropriate than other physicians. CONCLUSIONS:
Surveyed physicians agreed with clinical experts about the
appropriateness of coronary angiography after myocardial infarction
for most indications, indicating that well-designed expert panels can
closely reflect the views of practicing physicians. Variations in
beliefs among practicing physicians suggest that evaluations of
medical practice should incorporate the views of a range of relevant
types of physicians.
ARTICLE TITLE: Use and overuse of angiography and
revascularization for acute coronary syndromes [editorial;
comment]
COMMENTS: Comment on: N Engl J Med 1998 Jun 18; 338(25):1785-92
ARTICLE SOURCE: N Engl J Med (United States), Jun 18 1998, 338(25)
p1838-9
AUTHOR(S): Lange RA; Hillis LD
ARTICLE TITLE: Conflict of interest in the debate over
calcium-channel antagonists [letter]
ARTICLE SOURCE: N Engl J Med (United States), Jun 4 1998, 338(23)
p1697-8
AUTHOR(S): Strandgaard S
ARTICLE TITLE: Declining morbidity and mortality among patients
with advanced human immunodeficiency virus infection. HIV Outpatient
Study Investigators [see comments]
COMMENTS: Comment in: N Engl J Med 1998 Mar 26; 338(13):906-8
ARTICLE SOURCE: N Engl J Med (United States), Mar 26 1998, 338(13)
p853-60
AUTHOR(S): Palella FJ Jr; Delaney KM; Moorman AC; Loveless MO; Fuhrer
J; Satten GA; Aschman DJ; Holmberg SD
AUTHOR'S ADDRESS: Northwestern University Medical School, Chicago, IL
60611-0949, USA.
CONCLUSIONS: The recent declines in morbidity and mortality due to
AIDS are attributable to the use of more intensive antiretroviral
therapies.
ARTICLE TITLE: Progress and problems in the fight against AIDS
[editorial; comment]
COMMENTS: Comment on: N Engl J Med 1998 Mar 26; 338(13):853-60
ARTICLE SOURCE: N Engl J Med (United States), Mar 26 1998, 338(13)
p906-8
AUTHOR(S): Hirschel B; Francioli P
ARTICLE TITLE: Ethics of placebo-controlled trials of zidovudine
to prevent the perinatal transmission of HIV in the Third World
[letter]
ARTICLE SOURCE: N Engl J Med (United States), Mar 19 1998, 338(12)
p839-40; discussion 840-1
AUTHOR(S): Lallemant M; McIntosh K; Jourdain G; Le Coeur S;
Vithayasai V; Lee TH; Hammer S; Prescott N; Essex M
PUBLICATION TYPE: LETTER
ARTICLE TITLE: Ethical issues in studies in Thailand of the
vertical transmission of HIV [see comments]
COMMENTS: Comment in: N Engl J Med 1998 Mar 19; 338(12):843-4;
Comment in: N Engl J Med 1998 Mar 19; 338(12):844
ARTICLE SOURCE: N Engl J Med (United States), Mar 19 1998, 338(12)
p834-5
AUTHOR(S): Phanuphak P
AUTHOR'S ADDRESS: Thai Red Cross Society, Bangkok.
PUBLICATION TYPE: LETTER
ARTICLE TITLE: Reduction in pulmonary vascular resistance with
long-term epoprostenol (prostacyclin) therapy in primary pulmonary
hypertension [see comments]
COMMENTS: Comment in: N Engl J Med 1998 Jan 29; 338(5):321-2
ARTICLE SOURCE: N Engl J Med (United States), Jan 29 1998, 338(5)
p273-7
AUTHOR(S): McLaughlin VV; Genthner DE; Panella MM; Rich S
AUTHOR'S ADDRESS: Section of Cardiology, Rush Medical College,
Rush-Presbyterian-St. Luke's Medical Center, Chicago, IL 60612-3824,
USA.
CONCLUSIONS: In primary pulmonary hypertension, long-term therapy
with epoprostenol lowers pulmonary vascular resistance beyond the
level achieved in the short term with intravenous adenosine.
Epoprostenol appears to have sustained efficacy in this disorder.
ARTICLE TITLE: Pulmonary hypertension--beyond vasodilator therapy
[editorial; comment]
COMMENTS: Comment on: N Engl J Med 1998 Jan 29; 338(5):273-7
ARTICLE SOURCE: N Engl J Med (United States), Jan 29 1998, 338(5)
p321-2
AUTHOR(S): Fishman AP
TITLE: Effects of walking on mortality among nonsmoking retired
men.
ARTICLE SOURCE: N Engl J Med (United States), Jan 8 1998, 338(2)
p94-9
AUTHOR(S): Hakim AA; Petrovitch H; Burchfiel CM; Ross GW; Rodriguez
BL; White LR; Yano K; Curb JD; Abbott RD
AUTHOR'S ADDRESS: Division of Biostatistics, University of Virginia
School of Medicine, Charlottesville 22908, USA.
CONCLUSIONS: Our findings in older physically capable men indicate
that regular walking is associated with a lower overall mortality
rate. Encouraging elderly people to walk may benefit their
health.
ARTICLE TITLE: Conflict of interest in the debate over
calcium-channel antagonists.
ARTICLE SOURCE: N Engl J Med (United States), Jan 8 1998, 338(2)
p101-6
AUTHOR(S): Stelfox HT; Chua G; O'Rourke K; Detsky AS
AUTHOR'S ADDRESS: Department of Medicine, University of Toronto, ON,
Canada.
ABSTRACT: BACKGROUND: Physicians' financial relationships with the
pharmaceutical industry are controversial because such relationships
may pose a conflict of interest. It is unknown to what extent
industry support of medical education and research influences the
opinions and behavior of clinicians and researchers. The recent
debate over the safety of calcium-channel antagonists provided an
opportunity to examine the effect of financial conflicts of interest.
METHODS: We searched the English-language medical literature
published from March 1995 through September 1996 for articles
examining the controversy about the safety of calcium-channel
antagonists. Articles were reviewed and classified as being
supportive, neutral, or critical with respect to the use of
calcium-channel antagonists. The authors of the articles were asked
about their financial relationships with both manufacturers of
calcium-channel antagonists and manufacturers of competing products
(i.e., beta-blockers, angiotensin-converting-enzyme inhibitors,
diuretics, and nitrates). We examined the authors' published
positions on the safety of calcium-channel antagonists according to
their financial relationships with pharmaceutical companies. RESULTS:
Authors who supported the use of calcium-channel antagonists were
significantly more likely than neutral or critical authors to have
financial relationships with manufacturers of calcium-channel
antagonists (96 percent, vs. 60 percent and 37 percent, respectively;
P 0.001). Supportive authors were also more likely than neutral or
critical authors to have financial relationships with any
pharmaceutical manufacturer, irrespective of the product (100
percent, vs. 67 percent and 43 percent, respectively; P 0.001).
CONCLUSIONS: Our results demonstrate a strong association between
authors' published positions on the safety of calcium-channel
antagonists and their financial relationships with pharmaceutical
manufacturers. The medical profession needs to develop a more
effective policy on conflict of interest. We support complete
disclosure of relationships with pharmaceutical manufacturers for
clinicians and researchers who write articles examining
pharmaceutical products.
ARTICLE TITLE: Management of life-threatening acid-base disorders.
First of two parts.
ARTICLE SOURCE: N Engl J Med (United States), Jan 1 1998, 338(1)
p26-34
AUTHOR(S): Adrogue HJ; Madias NE
AUTHOR'S ADDRESS: Department of Medicine, Baylor College of Medicine
and Methodist Hospital, Houston, USA.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (68 references); REVIEW,
TUTORIAL