From the journals, August 2004

New Eng J Med Vol 351

543 The modern management of heart failure consists largely of blocking the renin-angiotensin-aldosterone system comprehensively, and the RALES trial showed that adding spironolactone to existing treatment improved survival by nearly 30%. Only, try not to kill the patient with hyperkalaemia — it didn't happen in the trial, but happened rather often when keen GPs in Ontario adopted the new treatment without due caution.

637 Are you a smart defibrillator? If you are trained to use the machine, you might by remote chance save somebody with out-of-hospital cardiac arrest — 19 000 American volunteers just reached statistical significance. Training them in advanced life support brought no further benefit.

681 A brisk US review of generalised anxiety disorder tells you to prescribe serotonin reuptake inhibitors and benzodiazepines and cognitive behavioural therapy — more like British general practice than Frasier.

868 Surprisingly, children who have to take high-dose steroids for long periods to control nephrotic syndrome do not lose bone mineral.

876 For recurrent vaginal thrush, weekly fluconazole 150 mg works well — but two-thirds of patients relapse in the year after stopping it.

Lancet Vol 364

521 Should we be throwing away all sorts of surgical instruments, for fear of Creutzfeldt-Jakob Disease? Probably not, since a wide range of decontamination methods work, including some that do not destroy electronic parts.

533 Kawasaki syndrome is something you may never see, but should never miss: here are some pictures to fix it in your mind.

621 Faecal incontinence — common, and, according to this review, mostly curable.

633 Tucked away at the back of the Lancet, under an obscure title, a magnificent essay by Julian Tudor Hart in praise of a non-market health service.

665 COX-2 inhibitors are relatively benign to the gastrointestinal tract, unless combined with aspirin (have you done your practice audit?). Some may also be benign to the heart, but there is evidence against rofecoxib, in favour of celecoxib, and neutral for lumaricoxib.

703 Staphylococci like to live at the end of the nose, with occasional sorties to other places when they sniff an opportunity. Patients own germs cause 80% of hospital staphylococcal infections: they should be made to wear candles at the end of their noses to reduce spread, like the Dong with a Luminous Nose.

753 Much learned correspondence about the huge protective effect of fresh fruit and vegetables against cardiovascular disease reported in the Norfolk-EPIC study: just an artefact, or the most important lifestyle factor of all?

JAMA Vol 292

704 Chickenpox vaccine prevents 80% of chickenpox, and the rest milder and less contagious.

807 A study of adolescent depression, showing that fluoxetine works better than cognitive behavioural therapy, but combining the two works best.

828 Vitamin E — is it good for anything? Not for preventing lower respiratory tract infections in nursing home residents, but those taking vitamin E had far fewer colds or upper respiratory infections.

847 Surgical mortality statistics are a useless guide to hospital quality, except perhaps for coronary bypass grafting.

935 Using the telephone to follow up patients on antidepressants seems to improve compliance, deliver behavioural advice, and improve outcomes.

Other Journals

Are patient self-management education programmes worth the effort? Arch Intern Med (164: 1641) carries a large systematic review, showing small benefits or none in most areas. Ann Intern Med (141: 178) reports on the use of terminal sedation to hasten death in the Netherlands; page 292 carries a debate about the clear superiority of primary angioplasty over thrombolysis in myocardial infarction. Despite the mass of trial evidence, there are sceptics, even in the US. Rheumatology (43: 1034) analyses the effect of anti-TNF therapy on patient satisfaction in rheumatoid arthritis: generally favourable, as one would expect from a treatment which, combined with methotrexate, should be the gold standard (see correspondence in NEJM 351: 937). Does your mobile phone really need to be switched off when you visit patients in hospital? Unfortunately, yes: a systematic review in Med J Australia (181: 145) confirms that they need to be kept at least 1 metre from some medical equipment. It's no secret, meanwhile, that sildenafil often helps men to gain height in certain regions, but did you know that Everest base camp is one of them? Ann Intern Med (141: 169) reports a randomised trial there, showing that the drug improves exercise capacity in hypoxic conditions, thus helping the chaps to keep on going up.