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BMJ. 2007 March 31; 334(7595): 702.
PMCID: PMC1839235

Minerva

Getting the acetabular “cup” component position “just right” in total hip replacement is essential to reduce risk of dislocation and loosening and to optimise the range of motion. A comparison of imageless computer assisted navigated insertion with freehand positioning showed that computerised navigation improved performance by significantly reducing the number of outliers—that is, cups placed outside the defined safety zone (Journal of Bone and Joint Surgery 2007;89B:494-9, doi: 10.2106/JBJS.F.00529). The downside is that computerised navigation took about 20 minutes longer than manual positioning.

Older versions of the BCG vaccine may offer better protection against tuberculosis than some of the newer ones, according to a study in the Proceedings of the National Academy of Sciences of the USA (2007 Mar 19, doi: 10.1073/pnas.0700869104). Scientists compared the entire genetic sequence of several BCG strains and found many differences introduced as the microbe has been cultured over time. The early strain called BCG Japan, dating from before 1925, triggered a more powerful immune response in infants than BCG Danish, Glaxo, and Pasteur, which together accounted for 66% of the vaccine doses administered in 1996.

Thirty years on, and data from the first prospective Northwick Park heart study show that the impact of haemostatic variables on fatal coronary heart disease persists (Journal of Thrombosis and Haemostasis 2007;5;461-71, www.journalth.com/showPage.php?template=Articolo&id=16319). Factor VII anticoagulant activity and plasma fibrinogen were measured as patients were recruited to the study. Recruitment levels of anticoagulant activity were significantly related to death from heart disease in both sexes, but fibrinogen at recruitment was related to death from heart disease only in men.

Duct tape is no better than moleskin pads for treating warts and may be worse, according to a double blind randomised controlled trial of immunocompetent adults with longstanding warts (Archives of Dermatology 2007;143:309-13, http://archderm.ama-assn.org/cgi/content/full/143/3/309). A fifth of both duct tape group (21%) and controls (22%) achieved complete resolution. But of participants whose target wart was completely resolved, 75% of the duct tape group but just 33% of the controls had a recurrence of the wart within six months.

There's a stark difference in India between poorly resourced hospitals used almost entirely by the indigenous population and the 45 or so new centres of medical excellence, which are enjoying an increasing trade in medical tourism. Medical tourists are flocking in droves to India's overseas offices to apply for M visas, which are valid for up to a year and can also be issued to travel companions. Certified hospitals must agree to limit charges to foreigners as part of a dual pricing system that offers domestic patients lower prices (Bulletin of the World Health Organization 2007;85:164-5, www.who.int/bulletin/volumes/85/3/07-010307/en/index.html).

More than 10 years ago scientists proposed cell replacement therapy to treat heart failure. Research showed that the best way forward was to use non-committed stem cells that could potentially be induced to become cardiomyocyte-like. Despite the lack of biological precedent and rationale, haematopoietic stem cells seemed to improve cardiac function, and clinical trials have been pursued, albeit with difficulties about how best to minimise the placebo effect. Safety concerns remain, but as an editorial in the Journal of Thoracic and Cardiovascular Surgery argues, “a few good men and women are needed” now for a good, blinded, randomised controlled study (2007;133:599-600, http://jtcs.ctsnetjournals.org/cgi/content/full/133/3/599).

Bronchodilators are routinely recommended for patients with asthma undergoing flexible bronchoscopy. The procedure is thought to be safer in patients with chronic obstructive pulmonary disease because of lower levels of bronchial hyper-responsiveness. But when put to the test in a randomised, placebo controlled trial, rather than being protective, premedication with an inhaled short acting β agonist in chronic obstructive pulmonary disease proved as problematic as placebo in causing bronchoconstriction after bronchoscopy (Chest 2007;131:765-72, doi: 10.1378/chest.06-2308).

Survivors of cardiac arrest don't do well, and many sustain anoxic brain injury even if they do survive. Inducing hypothermia is known to reduce the effects of cerebral anoxia, and some places now recommend that cooling of cardiac arrest survivors be instituted quickly, even though the efficacy of interventions such as thrombolysis and stenting may be affected. Depending on the size of the patient 20-50 ice packs are required, which can be a problem for some emergency departments. Raiding the hospital cafeteria for ice may be necessary (CMAJ 2007;176:759-62, doi: 10.1503/cmaj.051578).


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