Elements: In this month's issue
This month's review represents yet another discussion of the use of statins. This group of drugs has for long been considered to be both efficacious and safe in the treatment and prevention of cardiovascular disease (CHD). However the possibility of interaction between statins with other drugs also used in the management of CHD has been raised. Thienopyridines because of their anti-platelet effects are frequently administered to patients in order to reduce morbidity and mortality from CHD. One of the more commonly used thienopyridines, clopidogrel, is metabolised in the liver by means of the cytochrome CYP 3A4 system to become an active compound which then inhibits platelet receptors. It should be noted that statins are also metabolised by the same CYP 3A4 system. Hence, there is a hypothetical risk for the inhibition of the platelet aggregation effects of clopidogrel to be dangerously increased by the simultaneous administration of statins. However, the extensive review by Bhindi and colleagues from Oxford offer some reassurance in this respect to clinicians. No compelling clinical evidence to discontinue the co-administration of statins and clopidogrel was found as a result of their review of the available literature. It would seem, therefore, that the benefits to patients of this joint therapeutic regime outweigh theoretical adverse outcomes due to drug interaction.Professor McCance makes a welcome reappearance this month in order to demonstrate his wisdom, teaching skills and formidable prowess in applied physiology. The subject for consideration is that of Bartter's Syndrome – a condition that is often misunderstood (and misspelt). We are reminded that Bartter's Syndrome is caused by impairment of NaCl reabsorption in the ascending loop of Henle. The subsequent discussion considers the effects of Na+ absorption without water and the therapeutic action of indomethacin in this disorder. The co-existence of nephrogenic diabetes insipidus in some patients with Bartter's syndrome is also discussed in some detail. Finally an important point is made: our knowledge of physiology has moved on considerably from when most of us received out undergraduate teaching. Hence some of the long held certainties which we have held on to for decades must be discarded in the light of new evidence.
In addition to review articles and primary research papers, QJM also welcomes submissions that consider evaluation of the delivery of clinical services, particularly when the subject area is of significant importance and when there are agreed standards. Cunnington et al, from Newcastle, explored the reasons for delay in implementing permanent pacemaker implantation (PPM). They undertook a prospective observational study from a regional pacing centre. The findings would, on the face of it, indicate considerable scope for improvement. There are still significant delays to PPM implantation which were significantly longer in those patients treated electively than those managed as emergencies. The authors conclude that much of the delay was due to process issues; but a substantial proportion of patients experienced delays caused by failure of referral once an indication for pacing was documented. This indicated a need for increased awareness of the latest guidelines among front line clinicians representing perhaps an educational objective for both doctors in training as well as their supervisors.
A group from Northern Ireland have completed a long term (10 years) retrospective view of their experience with renal transplantation. Over 1,000 patients who had renal transplantation performed between 1976 and 2006 were studied in terms of outcome. This study provides a useful insight into changes in trends over four decades. Overall, outcomes were observed to be greatly improved for this group of patients. However improved survival and reduced rejection rates would seem to come at a price. A worrying trend resulted from an observed increase in malignancy among survivors. The findings from this study are put into a broader perspective by the accompanying commentary from O’Callaghan.
I don’t often draw readers’ attention to case reports. However this month's issue includes the extraordinary story of a young man in India who developed respiratory failure as a result of Guillain-Barré syndrome. This was a remarkable case, not because he required assisted ventilation, but that it was necessary for this to be delivered manually by his family.
Finally, we see the return of CODA. This section of the journal has been absent for many months since the departure of John Launer. After some reflection at QJM, it was decided to allow a number of authors to write reflective pieces for, the first of which is by Jeffrey Aronson who considers ordinary words with extraordinary meanings.
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