Australian doctors are encouraged to calculate each patient’s cardiovascular risk before prescribing cardiovascular drugs but, according to Davis et al, the commonly used equations may not be very accurate for people with type 2 diabetes. Among a group of 815 people who took part in the Fremantle Diabetes Study, the Framingham equation predicted 28% fewer coronary heart disease (CHD) events than actually occurred over 5 years of follow-up. The United Kingdom Prospective Diabetes Study (UKPDS) equations moderately overestimated the risk of both fatal and non-fatal CHD, slightly overestimated the risk of overall stroke, and underestimated the risk of fatal stroke. In the light of their findings, the authors conclude that the UKPDS stroke risk equation could be used in this population, but that both the UKPDS CHD risk equation and the Framingham equation were unsuitable (→ Comparison of the Framingham and United Kingdom Prospective Diabetes Study cardiovascular risk equations in Australian patients with type 2 diabetes from the Fremantle Diabetes Study).
At the other end of the diabetes spectrum, a small number of children with new-onset type 1 diabetes mellitus (T1DM) seem to be slipping into diabetic ketoacidosis (DKA) while waiting for formal blood test results before presenting to hospital (Craig et al, Letters, → Delayed referral of new-onset type 1 diabetes increases the risk of diabetic ketoacidosis). Among 150 children who had seen a GP before presenting to hospital with newly diagnosed T1DM, those whose referral letters indicated suspected T1DM were less likely than those who arrived with other provisional diagnoses to have DKA, as were those who arrived within 24 hours of seeing their GP. While most children had had simple bedside investigations such as a fingerprick test or urinalysis, about a third had been sent for formal blood tests, and these children were likely to present to hospital later, with DKA.
Living with psychosis
All serious mental illness, says Lambert, is associated with undue medical morbidity and mortality (→ The medical care of people with psychosis). The reasons are complex but include lifestyle issues stemming from the mental illness itself, medication side effects and problems with access to good medical care. Several articles in this issue touch on this important subject.
Heart disease causes most of the excess mortality in people with mental illness. A cross-sectional study by John et al found that more than half of the 203 patients attending a public mental health service and taking antipsychotic medications met the criteria for the metabolic syndrome (almost double the rate in the general population) (→ Prevalence of metabolic syndrome among Australians with severe mental illness). The association has been noted elsewhere, prompting Waterreus and Laugharne to develop a simple algorithm that can be used by clinicians to detect and manage the metabolic syndrome in patients with psychosis (→ Screening for the metabolic syndrome in patients receiving antipsychotic treatment: a proposed algorithm).
The atypical antipsychotic agent clozapine has been associated with direct cardiotoxic effects: between 0.7% and 1.2% of patients develop myocarditis, while much rarer adverse effects are cardiomyopathy and pericarditis. Transthoracic echocardiography can be useful for early detection, say Layland et al (→ Clozapine-induced cardiotoxicity: a clinical update). Clozapine was also implicated in the case of a woman who developed vision-threatening ocular pigmentation (Borovik et al, “Ocular pigmentation associated with clozapine”). While this problem has been noted in patients taking chlorpromazine, this is the first reported case associated with the newer drug.
After years of believing that schizophrenia is simply the result of an unfortunate roll of the genetic dice, neurodevelopmental experts are beginning to re-examine its environmental determinants. The current thinking is far more nuanced than the old “nature versus nurture” arguments and is the subject of the MJA Supplement included with this issue.
On the other hand . . .
If you’re feeling contrary, or even just open minded, turn to the debate between Martin et al (→ eGFR — use beyond the evidence) and Johnson et al (→ Automated reporting of eGFR: a useful tool for identifying and managing kidney disease) on the use of estimated glomerular filtration rate (eGFR) to identify and monitor patients with impaired renal function and to titrate drug doses. You may also wish to consider Komesaroff and Kerridge’s point of view on the Australian Medical Council’s draft code of professional conduct (→ The Australian Medical Council draft code of professional conduct: good practice or creeping authoritarianism?), which may or may not be “oversimplifying the moral world, stripping ethics of its context and supporting an excessively rigid, restrictive and narrow moral regime”. And spare a thought for Johann Sebastian Bach: dead for more than 250 years and buried in an unmarked grave, his alleged remains are still the subject of intense speculation (Zegers et al, “Are the alleged remains of Johann Sebastian Bach authentic?”).
Cracker of a collaboration
Fans of the electronic news bulletin, Crikey, may have noticed that they have upped the ante on health reporting over the past year or so. In “CHAMP: a novel collaboration between public health and the media”, Sweet et al reveal that this is no coincidence, but the result of a novel collaboration between public health advocates and the media to form the Crikey Health and Medical Panel (CHAMP). The CHAMP contributions are well worth perusing, or if, to paraphrase Noel Coward, you believe that the Internet “is for appearing on — not for looking at”, you may like to submit a post of your own.
Another time . . . another place
Following chlorpromazine, a veritable cornucopia of anti-psychotic, antimanic, and antidepressant drugs poured forth, changing psychiatry from a branch of social work to a field that called for the most precise knowledge of pharmacology, the effect of drugs on the body.
Edward Shorter, 1997
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