eMJA: In Other Journals, 21 March 2005

The cardiovascular complications of cyclo-oxygenase-2 (COX-2) inhibitors appear to be a class effect, according to Dr Jeffrey Drazen, Editor-in-Chief of The New England Journal of Medicine (NEJM). Drazen was commenting on three research articles published on the NEJM website that report cardiovascular toxicity data for not only rofecoxib but also celecoxib, and valdecoxib and its intravenous prodrug, parecoxib. The data came from trials designed to test the efficacy of these agents for a variety of indications rather than associated risks. Data for celecoxib came from the Adenoma Prevention with Celecoxib study, a randomised, controlled trial involving 2035 patients in which celecoxib at a dose of 400 mg twice daily was associated with more than a tripling of the risk of cardiovascular events; 200 mg twice daily more than doubled the risk. US experts, who also commented on these results, say we know that COX-2 inhibitors inhibit the production of prostacyclin and favour vasoconstriction, which may increase the risk of cardiovascular events, including myocardial infarction, stroke, hypertension and heart failure. However, we lack adequate information to make confident statements about the exact levels of risk for each COX-2 inhibitor, the time course of the risk during therapy, and the population of patients, if any, in whom the benefits of therapy might exceed the risks. Drazen said it was reasonable to ask whether the use of COX-2 inhibitors can now be justified, given that there are well-established options for the treatment of all the approved indications for these drugs.

Early supported discharge of some stroke patients for rehabilitation at home can offer benefits for both the patient and the healthcare system, say international authors. They conducted a meta-analysis of data from 11 randomised trials from six countries, including Australia, which compared early supported discharge after stroke with conventional care. Patients who received an early supported discharge service were at reduced risk of death and of dependency, experienced fewer adverse outcomes and had improved scores for activities of daily living. The hospital stay for these patients was about 8 days shorter. The greatest benefits were seen in patients with mild to moderate disability.

Broken heart syndrome

US researchers have begun to unravel the mystery surrounding cases of profound but reversible left ventricular dysfunction that have occurred after sudden emotional stress. They studied 19 patients with this presentation, finding much higher levels of plasma catecholamines (ie, adrenaline, noradenaline and dopamine levels), neuronal metabolites and neuropeptides than in patients with Killip class III myocardial infarction. The researchers suggested that exaggerated sympathetic stimulation could be central to the cause of this "broken heart syndrome". They proposed microvascular spasm and direct myocyte injury as potential mechanisms of myocardial stunning.

N Engl J Med 2005; 352: 539-548

Missing in practice

Ever-increasing amounts of individual clinical information now seem necessary for the daily practice of medicine, say US experts.1 They suggested that patients could serve as a safety buffer in improving the communication of this data between different healthcare providers. For example, patients should be encouraged to keep a medication list and be provided with a synopsis of past hospitalisation and procedures that they can take with them to hospital emergency departments and consultants. The experts were commenting on a US survey that found that at least one piece of clinical information (such as a lab report or a letter) was missing from the medical record of nearly 1 in 7 of more than 1500 patient consultations conducted in a general practice setting.2 Doctors were spending valuable consultation time searching, often unsuccessfully, for missing pieces that could affect quality of care. Missing information was frequently reported to be located outside the practice, and the disjointed nature of healthcare delivery and privacy issues were considered to be factors contributing to the problem.

1. JAMA 2005; 293: 617-619
2. JAMA 2005; 293: 565-571

Keep on trying

In 1990, a 29-year-old patient with unexplained sub-fertility whose partner had moderate oligospermia embarked on a series of cycles of assisted reproductive technology (ART). 12 years later, in 2001, and after 37 cycles of ART and 26 embryo transfers in 22 attempts, a pregnancy was achieved and the couple took home a healthy male infant. The Australian authors of this case report say that this patient’s experience is in line with previous reports of in vitro fertilisation, which show that, in general, success depends on multiple attempts.

Aust N Z J Obstet Gynaecol 2004; 44: 580-582

Dr Ann Gregory, MJA

The Medical Journal of Australia eMJA