Can mothers be trusted to give malaria treatment to their children at home?

Children with symptomatic malaria in Bissau were randomly assigned to treatment with chloroquine 25 mg base/kg given supervised at a health centre or unsupervised by the mothers at home. On day 7, a blood sample for drug analyses was drawn and the children were then followed once weekly for 5 weeks. The data were analysed on an intention to treat basis. No differences were seen in the outcome of treatment nor in the blood drug concentrations on day 7 between the two groups. Mothers in Bissau can be trusted to give adequate anti-malarial medication to their children at home.     

Can bioprostheses be implanted at younger ages?

The choice between mechanical prosthesis (MP) and bioprosthesis (BP) depends on the respective advantages and disadvantages of the two types of valves. MP theoretically have an indefinite life span but carry the risk of thromboembolic events that requires anticoagulant therapy, which itself is responsible for hemorrhages. BP bear a theoretically lower thromboembolic risk but have a limited life span that requires reintervention at a subsequent date, latter when the patient is older at implantation and operated on for aortic replacement. Actually MP is preferred before 60 years and BP after 70 years. Between 60 and 70 years there is not consensus. The limit recommended is around 65 years for aortic replacement and 70 years for mitral replacement. This limit can change either for upper or lower limit depending on patient's life expectancy, technological improvements of MP as well as BP, improvements of medical follow up of anticoagulant therapy (either self testing or use of anti thrombin). In the future the age limit of implantation of BP can be lowered but MP didn't have their last word.     

Long-acting nitrates in portal hypertension: to be or not to be?

The major complication of portal hypertension is represented by gastrointestinal haemorrhage from ruptured oesophageal varices. Gold standard prophylaxis with non selective beta-blockers is able to decrease the risk of bleeding or rebleeding only in a fraction of patients, thus additional forms of treatment are under investigation. Long-acting nitrates have been considered the best candidates to improve the pharmacological response. The rationale for the use of nitrates in portal hypertension is primarily based on the fact that they lead to a decrease in the hepatic venous pressure gradient and on the knowledge that deficient intrahepatic nitric oxide release could be one of the mechanisms involved in the development of increased portal resistance in early cirrhosis. Ten randomised controlled trials have, so far, investigated the clinical usefulness of long-acting nitrates in portal hypertension. Five of them explored the field of primary prophylaxis and the others, the use of nitrates in the prevention of rebleeding. The results of these randomised controlled trials are partially contradictory as far as concerns prevention of bleeding or rebleeding, survival and treatment-related complications. A common finding emerging from most of these studies suggests that the potential for a beneficial or detrimental effect of nitrates depends on the stage of liver disease and the extension of portal collaterals. Thus, in the early stage of cirrhosis, it would be desirable to target nitrates to the liver microvasculature, while, in a later stage, nitrates could be deleterious by aggravating the hyperdynamic syndrome through the expansion of the vascular bed. Whether or not nitrates may have a role in the primary and/or secondary prophylaxis of bleeding needs to be addressed in further long-term studies.     

Can aneroid sphygmomanometers be used at altitude?

Mercury-independent devices are increasingly being used in clinical practice as mercury will soon be removed from clinical use as a result of environmental, health and safety concerns. The aim of this study was to evaluate the accuracy of a portable aneroid device in an adult population at high altitude by following the part of the protocol of the British Hypertension Society regarding comparison between device and observer. We examined 10 subjects in Cerro de Pasco, Peru, which is situated 4370 m above sea level. The aneroid device was initially calibrated at both high altitude and at sea level to ensure optimal function. Validation of the device was undertaken at high altitude by connecting it in parallel to two mercury sphygmomanometers. Eleven sequential same-arm measurements were taken from each subject by two trained observers, alternating between mercury sphygmomanometry and the aneroid device. Simultaneous mercury readings were also recorded for additional analysis. During calibration, all 60 comparisons between the aneroid and mercury sphygmomanometers were within 3 mm Hg both at sea level and at high altitude. At validation, the device achieved an A grade for both systolic and diastolic pressures and also fulfilled the requirements of the Association for the Advancement of Medical Instrumentation. The mean and standard deviation for systolic and diastolic pressures, respectively, were -1.32 (4.3) mm Hg and 3.7 (4.7) mm Hg in sequential analysis and -0.7 (2.6) mm Hg and -3.3 (2.7) mm Hg in simultaneous analysis. We conclude that the Riester-Exacta portable aneroid device can be recommended for use in an adult population at high altitude.     

Patients at the outpatient rheumatology clinic: do they really need to be there?

BACKGROUND: The workload at many outpatient clinics within the Dutch health care system has been growing relentlessly, resulting in unacceptable waiting lists and reduced accessibility. Assessing streams of patients and introducing a method of accelerated referral of patients back to the general practitioner (GP) under specialist guidance could help to alleviate these problems. METHODS: Seventeen GPs collaborated with rheumatologists during a 2-year period in a 'joint consultation' model in which GPs and rheumatologists discussed patients together. All patient charts belonging to patients who had been referred to the outpatient clinic by these 17 GPs were identified. Rheumatologists assessed whether or not these patients could be referred back to the participating GPs under the guidance of the specialist in the joint consultation model. RESULTS: Of 276 eligible patients, 121 were discharged from the outpatient clinic. Eighty-seven patients required specialist follow-up, 22 patients refused to participate, and six patients were not entered into the study by the rheumatologist. Some 21 patients eventually entered the study, 18 of whom were referred back to the GP. CONCLUSION: The role of joint consultation appears to be limited. Improving the referral behavior of GPs should take precedence over transferring follow-up from the outpatient clinic to the primary care level.     

Should chloroquine be laid to rest?

Chloroquine (CQ) has been the front line antimalarial drug due to its efficacy, low cost and scanty side effects, until resistance has evolved. Although its use has been officially discontinued in most malaria-affected countries, it is still widely used. Practical and pharmacological considerations indicate that it could be still used in semi-immune adults and that more efficient treatment protocols could be devised to treat even patients infected with CQ-resistant parasite strains. Since its antimalarial activity is pleiotropic, drug resistance may be due to different mechanisms, each amenable to reversal by drug combination.     

Bridge to recovery: what remains to be discovered?

The use of left ventricular assist devices to induce substantial myocardial recovery with explantation of the device, bridge to recovery (BTR), is an exciting but currently grossly underused application. Recently acquired knowledge relating to BTR and its mechanisms offers unprecedented opportunities to streamline its use and unravel some of the secrets of heart failure with much wider implications. This article reviews the status, challenges, and future of cardiac recovery.