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  1. RICHARD LEHMAN, MRCGP, MA
  1. Department of Primary Care, Oxford University
 Oxford, UK

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    The world of cardiology has been in turmoil ever since the first studies which showed that immediate angioplasty is superior to thrombolysis for acute myocardial infarction. Even on an overcrowded island like Britain, most people do not live within easy distance of a cardiac catheter facility, and even in a resource rich country like the USA, there aren’t enough cardiologists to provide a 24 hour immediate angiography service. A thorough systematic review and economic analysis in the British

    finds that 6 month mortality is reduced by about one third, and reinfarction by a half, but that these benefits may be lost if door-to-balloon time is more than an hour longer than door-to-needle time. But a German trial published in found a benefit even in patients presenting more than 12 hours from the first symptoms of myocardial infarction. Fortunately, there is growing evidence that thrombolysis followed by invasive treatment may achieve most of the benefits of immediate angioplasty without the logistic nightmares. Open any major cardiology journal and you will probably find someone reporting or opining about this (eg,
    ).Everybody who has coronary artery disease should take at least 2 drugs every day, and it seemed for a time that antibiotics might figure in the cocktail too. But early hopes from case control studies and early trials, showing that people seemed less likely to have an acute coronary event if they had been given antibiotics active against Chlamydia trachomatis, have not been borne out by randomised trials in people with existing coronary disease (meta-analysis, ).Most chest pain presenting in primary care is non-cardiac, and a good deal of it is attributed to gastro-oesophageal reflux and managed with a trial of proton pump inhibitors (PPI). Two groups, one Chinese (
    ) and the other American (
    ) have meta-analysed the studies and come up with a broadly similar conclusion: that PPI testing is useful. But for those interested in systematic reviews of diagnostic tests, the differences in selection and reporting are instructive.Despite the promise of direct thrombin inhibitors at fixed dosage, it looks like we have to fiddle about with warfarin and international normalised ratio monitoring for some time to come, in a constantly increasing number of patients. We tend to assume that the drug and food interactions of warfarin are well understood, but a large overview (
    , looking at 642 citations, 181 eligible articles) of the literature shows otherwise. There are one or two inconsistencies—paracetamol and acetaminophen are reported with different levels of interaction, though they are the same drug! And the tables show that it is more important to avoid grapefruitjuice than alcohol, though the text mentions only the latter.Does anything really relieve the pain of knee joint osteoarthritis? We have visited this on a number of occasions, and found, for example, that sham acupuncture works as well as real acupuncture. Now comes an RCT (
    ) showing that sham physiotherapy works as well as real physiotherapy. Real gels and injections probably work better than fake ones, and so do oral NSAIDs, but not for very long. Maybe it would be safest to refer our hobbling patients to registered snake-oil salesmen and bogus therapists?Neutropenic fever can be a frightening and life threatening complication of many chemotherapeutic regimes for cancer. A meta-analysis of antibiotic prophylaxis in neutropenia shows that antibiotics reduce episodes of fever, and that if the chosen antibiotic is a fluoroquinolone, it can reduce mortality (
    ).London used to be a bad place to be born: remember the baby dropped out of the gin-soaked mother’s arms in Hogarth’s engraving, or Blake’s stunning Song of Experience where “the youthful Harlot’s curse/ Blasts the new-born infants tear/ And blights with plagues the Marriage hearse.” Even at the start of the twentieth century, Somerset Maugham, writing Of Human Bondage from his experiences of London as a medical student, dwells on the plight of an anaemic prostitute. A recent study (
    ) of 222 614 London births shows that maternal anaemia below a haemoglobin of 9g/dl is still associated with increased perinatal mortality.How old do you feel? A Finnish study shows that older people’s perceived age is significantly related to their survival (
    ). Ask me on a Friday evening, and I’d soon be dead.“The effectual fervent prayer of a righteous man avails much” James 5.16. Though I was devoutly brought up, this didn’t seem to work for me, and it didn’t work for the participants in the MANTRA II trial either, when they prayed for randomised patients undergoing cardiac interventions (). Maybe, like me, they weren’t sufficiently fervent or righteous, or maybe James didn’t mean to include interventional cardiology.

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