In Other Journals

Solar system

Indian researchers have found a simple, very inexpensive way for health workers in developing countries to treat infectious material.1 They immersed simulated and real infectious medical-waste in water within a solar box-cooker. After 6 hours of solar exposure reaching temperatures of 68°-87°C, the viable population of a range of common pathogens decreased — by a 7 log reduction — to fewer than 10 colony-forming units or bacteria/mL.

Commentators point out ways in which solar cookers can achieve even higher temperatures and faster inactivation times and another plus: solar cookers don't have the problems that come with electrical components or moving parts.2

1. Lancet 2003; 362: 1285-1286 2. Lancet 2003; 362: 1251-1252

Head first

Moves are afoot in North America to obtain funding for a "term cephalic trial" — a randomised study that will compare primary elective caesarean section (ECS) with vaginal birth for uncomplicated pregnancies with a cephalic presentation at term, report Canberra authors. This follows an apparent narrowing of the difference in cost and outcome of either delivery mode in the uncomplicated setting, and increasing requests from women for ECS in the absence of any clear obstetric indication. In an opinion piece, the Canberra authors say that any such trial would add useful evidence for pregnant women and their carers to consider when choosing a preferred method of birth.

Aust N Z J Obstet Gynaecol 2003; 43: 341-343

Adverse events: costly; not always preventable

The financial burden of "medical injuries" in the USA can be high, say researchers.1 They examined costs associated with 18 specific injuries documented in 7.45 million discharge abstracts from acute-care hospitals across 28 states in 2000. Post-operative sepsis had the greatest impact (with hospital stays extended by nearly 11 days and charges increased by more than US $50 000 per patient) followed by postoperative wound dehiscence.

Across the Pacific, NZ researchers found that for almost two-thirds of detected adverse events there was little or no evidence of preventability.2 Many of the non-preventable events occurred operatively.

1. JAMA 2003; 290: 1868-1874 2. www.nzma.org.nz/journal/116-1183/624/

Walk on

US researchers report that, compared with placebo, a year’s treatment with the lipid-lowering agent atorvastatin increased pain-free walking time, if not maximal walking time. In their randomised, double-blind trial of 354 patients with intermittent claudication, they also noted a reduction in peripheral vascular events, such as worsening claudication and rest ischaemia, in the statin-treated groups.

Circulation 2003; 108: 1481-1486

SIRIUS business

With the advent of drug delivery from intravascular stents, endoluminal therapy for coronary artery disease is likely to produce similar or even better results than bypass surgery in most patients, according to a Swiss author in the Lancet.1 He was commenting on the European arm of the SIRIUS program (E-SIRIUS) which has found that sirolimus-eluting stents are markedly superior to bare-metal stents in preventing early restenosis in complex coronary lesions — relatively longer lesions in smaller arteries that may be managed with multiple stents.2 Further, the reduced need for repeat target-lesion revascularisation contributed to fewer major adverse cardiac events over 9 months of follow-up. The US arm of the program (SIRIUS) has also been published, with similar findings.3

1. Lancet 2003; 362: 1088-1089 2. Lancet 2003; 362: 1093-1099 3. N Engl J Med 2003; 349: 1315-1323

Ottawa rules

When it comes to deciding whether to order a plain x-ray in suspected fracture of the knee, the Ottawa rules are the best of the available clinical prediction rules, say US reviewers. This finding is one of several reported from their systematic literature review of the usefulness of history, physical examination and imaging in assessing acute pain of the knee.

The Ottawa knee rules are that, in acute knee injury, a plain film is needed to assess for fracture if the patient has at least one of four characteristics — age older than 55 years, tenderness at the head of the fibula or isolated to the patella, an inability to flex the knee to 90°, and an inability to weight-bear for at least four steps (some limping allowed).

A well-documented follow-up plan is recommended for all patients, as these rules will miss the diagnosis in three of 1000 patients who have an initial negative x-ray and, rarely, in those patients who do not proceed to x-ray.

Ann Intern Med 2003; 139: 575-588

— Dr Ann Gregory, MJA