Journal of the New Zealand Medical Association, 25-September-2009, Vol 122 No 1303
The authors of this paper point out that guidelines recommend prescription of antibiotics in children with severe acute otitis media and in those under 2 years of age with bilateral acute otitis media or acute otorrhoea. For most other children with acute otitis media, initial observation is recommended. Such prescribing may shorten the course of the illness but may tend to over treatment. Their prospective trial involved 168 children aged 6 months to 2 years with acute otitis media in 53 general practices in the Netherlands. Half were treated with amoxicillin 40 mg/kg/day and the other half with placebo.
After 3.5 years they found that acute otitis recurred in 63% of the amoxicillin-treated group and 43% in the placebo group. Subsequent referral for secondary care was necessary in 30% of both groups. Their conclusion was that antibiotics are overused in such patients and should be used more judiciously.
Apparently radiologists are in short supply in the UK and some departments have difficulty in providing reports on chest X-rays (CXRs) within 24 hours. Consequently CXRs are often viewed and acted upon by non-radiologists. In this study 60 clinicians of different grades and from different specialties were randomly recruited to interpret 15 CXRs within 30 minutes. Five CXRs were normal and the other 10 demonstrated common emergencies—pneumonia, pneumothorax, heart failure, etc. The results were as expected—senior doctors (consultants) and registrars were better than junior doctors. And specialists (consultants and registrars in radiology and chest physicians) were better than non-specialist senior doctors.
So they recommend that “to improve patient care we suggest that all chest X-rays should be reviewed at an early stage during a patient’s hospital admission by a senior clinician and reported by a radiologist at the earliest opportunity.” Can’t argue with that. I believe that this is standard practise in New Zealand—certainly is in my experience. An editorial commends the study and points out that regular clinician and radiologist meetings are very useful—both in achieving a timely accurate reports and educating junior doctors.
Postgraduate Medical Journal 2009;85:339–41 & 337–8.
Total hip replacement is a commonly performed and usually successful procedure. A major hazard of the metal-on-polyethylene bearing prosthesis is that wear and tear and osteolysis may result in instability and/or breakage. Hence the development of ceramic-on-ceramic total hip arthroplasty implants. Apparently they produce excellent clinical and radiographic results and do not fall apart as the earlier prostheses may. However, it has been reported that such “hard-on-hard” bearings may squeak. This paper reports on a cohort of patients equipped with ceramic-on-ceramic hip arthroplasties.
Fourteen (10.7%) of 131 patients described an audible squeak during normal activities. Only one of them had spontaneously complained about the squeak. Does it matter? Maybe—one squeaking prosthesis dislocated and needed replacing. However, two non-squeaking prostheses suffered the same fate. A matched cohort of metal-on-polythene showed no evidence of squeaking.
J Bone Joint Surg Am 2009;91:1344–9.
Most clinicians would probably regard a first-degree heart block to be benign. However, this follow up from the famous Framingham Heart Study may change our views. After excluding those with obvious cardiac problems, e.g. in atrial fibrillation, on digoxin, pacemaker in situ, etc they were left with a cohort of 7575 subjects (mean age 47 years, 54% female). This group had been recruited into the study between 1968 and 1974 and at baseline 124 had prolonged PR intervals in their ECG. When compared with the rest, this subset (i.e. prolonged PR intervals initially) had a two-fold risk for atrial fibrillation, a three-fold risk for pacemaker implantation, and a 1.4 increased risk of all-cause mortality.
Acute chest pain with a normal ECG—a common problem. The current troponin assay may be bedevilled as it may take several hours to become elevated, it may be only slightly elevated, or it may be chronically elevated. Two groups have reported on their experience with the sensitive TNI in comparison with other myocardial injury markers (conventional TNI, TNT, creatine kinaseMB, and myoglobin).
Both papers report that the sensitive TNI assay produces substantially better diagnostic information at an earlier time—as early as 3 hours after the acute chest pain. I note that myoglobin also appears to be a good early indicator of myocardial damage—much more so than the other compared tests. An editorial commentator is impressed with the results. He also points out that small elevations in troponin may not diagnose infarction but do have prognostic value—double the risk of recurrent ischaemia.
NEJM 2009;361:858–67, 868–77, 913–15.
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