February 25

Anticholinergic effects are common in many medicines prescribed to elderly people, such as antiemetics, antispasmodics, bronchodilators, psychotropics, and antihistamines. Marie Ancelin and colleagues compared 30 elderly French patients who continuously used drugs with anticholinergic effects for a year with 297 who did not. They found that the patients with �anticholinergic burden� were significantly more likely to have mild cognitive impairment than those who did not take these drugs. Interestingly, the treated group was no more likely to develop dementia, which makes one wonder whether the mild dementia was caused by drug side effects.

We are taught that smoking cessation attempts are more likely to succeed when smokers develop a strategy and make specific plans to quit. Robert West and Taj Sohal surveyed almost 2000 smokers and ex-smokers about their quitting experiences, asking whether their most recent quit attempt was planned in advance. Surprisingly, they found not only that almost half of the smokers� most recent quit attempts were made immediately on deciding to quit, but also that former smokers� successful quit attempts were significantly more likely to be unplanned than planned. So much for planned quitting!

Should patients in nursing homes be given cardiopulmonary resuscitation? Simon Conroy et al argue that the rate of successful CPR in nursing homes is very small, the risk of additional damage is high, and the costs are very high. They suggest that existing guidelines mandating CPR availability in nursing homes be reviewed.

Finally, in a Personal view, Ian Roberts urges doctors to lead by example in reducing our dependence on carbon based fuels. His essay from the future lauds us for becoming �carbon literate� and adopting low carbon lifestyles during a time of carbon rationing. A thoughtful warning about where we are heading.


February 18

Nina Buscemi and colleagues systematically reviewed the trials of exogenous melatonin for sleep disorders. They divided the research into studies of sleep problems associated with medical, neurological, or substance use disorders and studies of insomnia induced by jet lag or shift work. They found that melatonin is probably safe to use but ineffective for both types of sleep disorders, although Andrew Herxheimer points out in a helpful editorial that lumping together jet lag and shift work studies does not make sense physiologically.

Federico Venuta and Giulio Bognolo provide a useful update on current surgical efforts to treat patients with emphysema. In general, volume reduction surgery is recommended for older patients and those who are not candidates for lung transplantation. Promising minimally invasive surgery techniques are just now being tested in prospective trials.

Dupuytren�s contracture is a common problem in elderly men. W A Townley and associates review the anatomy and treatment of this problem, emphasizing that most cases do not require treatment. For best outcome, patients should be referred for surgical evaluation when contracture, especially proximal interphalangeal joint contracture, is first noted.

February 11

President Bush�s support for �consumer-directed health care� in his State of the Union address is criticized in an editorial by Princeton economics professor Uwe Reinhardt. Reinhardt argues that such plans favor the well-off and do nothing to address the large number of uninsured Americans.

Subcutaneous fondaparinux has been shown to reduce venous thromboembolism in orthopedic patients. In a randomized placebo-controlled trial, Alexander Cohen and colleagues found that it is also helpful in elderly hospitalized patients with chronic medical problems such as congestive heart failure, almost halving the rate of DVTs.

Chuanfang Lee et al systematically reviewed the evidence for the effects of hepatitis B immunoglobulin and vaccination on transmission of hepatitis B from mother to newborn. They found that both types of hepatitis B vaccine, immunoglobulin treatment, and the combination of vaccine and immunoglobulin all significantly reduced the risk of maternal transmission of hepatitis.

In a very helpful clinical review, Bernd Pohlmann-Eden and associates discuss the diagnosis and management of a first seizure in children and adults. They emphasize that the cause of seizures is often difficult to diagnose; many with �first� seizures have actually had previous unrecognized seizures; and most patients do not receive anti-epileptic medication after a first documented seizure.
 

February 4

Depression in the elderly is a common, relapsing disease. Enid Hunkeler and colleagues report a randomized treatment trial in US primary care settings, finding that drug and/or behavioral treatments delivered by a collaborative team are effective and long-lasting in the depressed elderly.

Caroline Daly et al have produced a useful tool for estimating prognosis in patients with newly diagnosed stable angina. Their multinational, prospective observational study allows the construction of a score based on comorbidity, symptom duration, and clinical findings. The score then predicts the likelihood of death or non-fatal myocardial infarction in the coming year.

A Agrawal and P J Whorwell review the diagnosis and treatment of irritable bowel syndrome in a paper prepared for www.bmjlearning.com. They point out that most of the newer drugs recommended for IBS when conservative measures fail are currently available in the United States, although not in the United Kingdom.

In a one-page �10-minute consultation�, Jane Haynes and Richard Haynes review the work-up of a patient who presents with asymptomatic �dipstick� proteinuria. Causes of transient proteinuria, such as urinary tract infection and heavy exercise, need to be ruled out before persistent proteinuria is diagnosed and evaluated.

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