Heavy cigarette smoking is strongly associated with rheumatoid arthritis (RA), particularly in patients without a family history of RA

OBJECTIVES

To investigate the potential relation between cumulative exposure to cigarette smoking in patients with or without rheumatoid arthritis (RA) and a positive family history of the disease.

METHODS

239 outpatient based patients with RA were compared with 239 controls matched for age, sex, and social class. A detailed smoking history was recorded and expressed as pack years smoked. Conditional logistic regression was used to calculate the association between RA and pack years smoked. The patients with RA were also interviewed about a family history of disease and recorded as positive if a first or second degree relative had RA. The smoking history at the time of the study of the patients with RA with or without a family history of the disease was compared directly with that of their respective controls. Patients with RA with or without a family history of the disease were also compared retrospectively for current smoking at the time of disease onset.

RESULTS

An increasing association between increased pack years smoked and RA was found. There was a striking association between heavy cigarette smoking and RA. A history for 41-50 pack years smoked was associated with RA (odds ratio (OR) 13.54, 95% confidence interval (95% CI) 2.89 to 63.38; p<0.001). The association between ever having smoked and RA was modest (OR 1.81, CI 1.22 to 2.19; p=0.002). Furthermore, cigarette smoking in the patients with RA without a positive family history of RA was more prevalent than in the patients with a positive family history of RA for ever having smoked (72% v 54%; p=0.006), the number of pack years smoked (median 25.0 v 4.0; p<0.001), and for smoking at the time of disease onset (58% v 39%; p=0.003).

CONCLUSIONS

Heavy cigarette smoking, but not smoking itself, is strongly associated with RA requiring hospital follow up and is markedly more prevalent in patients with RA without a family history of RA.

Implementation of antithrombotic management in atrial fibrillation

The aim of the study was to assess the extent to which published recommendations on the antithrombotic management of atrial fibrillation had been adopted into clinical practice in a busy district general hospital, and the impact of clinical audit on subsequent management. In the initial audit, 185 consecutive patients with atrial fibrillation were studied using their case notes to identify any further clinical risk factors for stroke. A management algorithm stratified patients with atrial fibrillation into high, moderate, or low risk of stroke according to the individual stroke risk factors. For patients at high risk, the correct treatment is warfarin unless there are specific contraindications. For patients at moderate risk, the correct management is aspirin unless there are specific contraindications. Patients at low risk should receive no thromboprophylaxis. The clinical risks of stroke and thromboprophylaxis on discharge from hospital were recorded. An extensive education programme on stroke prevention in atrial fibrillation was undertaken. Six months later a further 185 consecutive patients with atrial fibrillation were audited. Overall, a large proportion (306/370; 83%) of patients were at high risk of stroke. In the initial audit, antithrombotic management was correct in 89 patients (48%). In the follow up audit, antithrombotic management was correct in 135 patients (73%) (p < 0. 00001). If this improvement in management were extrapolated to all hospital patients in the United Kingdom, approximately 1400 strokes/year could be avoided. Despite broad consensus in recent publications, antithrombotic management of atrial fibrillation remains imperfect, with many patients exposed to unnecessarily high risk of stroke.

Old drug, new tricks: haloperidol inhibits secretion of proinflammatory cytokines

OBJECTIVES

It was noted that treatment of a patient with acute mania by haloperidol was associated with marked improvement in activity of rheumatoid arthritis. The objective of this study was to examine the effects of haloperidol on inflammatory cytokine release in vitro, as a potential mechanism to explain the in vivo anti-inflammatory effects of haloperidol.

METHODS

The effect of haloperidol on the production of inflammatory cytokines interleukin 1beta (IL1beta) and tumour necrosis factor alpha (TNFalpha) was measured in bacterial lipopolysaccharide stimulated whole blood cultures and on the promonocyte cell line THP-1, using commercial and in house enzyme linked immunosorbent assays to measure cytokine concentrations.

RESULTS

Haloperidol inhibited lipopolysaccharide stimulated production of both IL1beta and TNFalpha in vitro in a dose dependent manner and over a prolonged time period. Marked inhibition was seen over a range of concentrations of haloperidol from 0.5 microgram/ml to 50 microgram/ml, including those predicted to occur in the patient's blood.

CONCLUSIONS

Haloperidol treatment seemed to alleviate inflammation in rheumatoid arthritis. In vitro experiments would suggest that the mechanism is by direct inhibition of proinflammatory cytokine release. This phenomenon requires further investigation and may potentially lead to the development of novel treatment.

The Internet for healthcare professionals

The Internet is a useful clinical tool for information and communication. Resources that are available on the Internet include the Medline index, full-text articles, patient handouts, discussion lists, continuing education, medical and pharmaceutical texts, and case studies. This article summarizes the different types of resources available and teaches the basic skills for using the Internet to find medical information. Otolaryngology sites are listed and described.

Atovaquone and proguanil for Plasmodium falciparum malaria

BACKGROUND

The increasing spread of multidrug-resistant Plasmodium falciparum malaria emphasises the urgent need for alternative treatment regimens. The objective of the study was to establish the efficacy of a novel drug combination. We compared a combination of atovaquone and proguanil with amodiaquine in the treatment of acute uncomplicated P falciparum malaria in Lambaréné, Gabon.

METHODS

142 adults were randomly allocated either a combination treatment of atovaquone 1000 mg daily and proguanil 400 mg daily for 3 days or treatment with amodiaquine 600 mg on admission, 600 mg 24 h later, and 300 mg after a further 24 h. Symptoms and clinical signs were recorded and giemsa-stained thick blood smears were done every 12 h until patients had been symptom-free and aparasitaemic for 24 h. 126 patients were followed up for 28 days or until recrudescence.

FINDINGS

In the atovaquone plus proguanil group 62 (87%) of 71 patients were cured and only one had recrudescent infection. By contrast, the cure rate was significantly lower (p=0.022) with amodiaquine (51 [72%] of 71; there were 12 recrudescences in the amodiaquine group). Eight patients in each group were lost to follow-up. Patients treated with atovaquone plus proguanil complained of nausea (33%) and vomiting (29%), and the most commonly reported adverse effects of amodiaquine were pruritus (43%) and insomnia (27%).

INTERPRETATION

Atovaquone and proguanil was a highly effective and safe drug combination in patients with acute uncomplicated P falciparum malaria in Gabon.

A study to compare ibuprofen effervescent granules with ibuprofen tablets in the treatment of acute dental pain

PURPOSE OF STUDY

To compare both the speed of onset and efficacy of the analgesia produced by the effervescent granule formulation with that produced by the conventional-release tablet formulation of ibuprofen in patients suffering acute dental pain and to record the incidence and severity of any adverse events.

POPULATION STUDIED

Dental out-patients of either sex and over 16 years of age requiring surgical removal of unilateral or bilateral lower third molar teeth under general anaesthesia as day cases.

METHODS

A total of 50 patients received the effervescent granules formulation of ibuprofen 600 mg (Brufen Granules) as study treatment and 50 received the 600 mg tablet formulation in this investigator-blind, parallel-group multiple-dose study. Surgery was performed under general anaesthesia by one or two dental surgeons. Patients received either one sachet of ibuprofen granules or one tablet of ibuprofen at six-hourly intervals for up to 24 hours once post-operative pain became moderate to severe.

FINDINGS

Both treatments were shown to be efficacious in treating post-operative dental pain. The granules were found to give significantly better pain relief in the first 30 minutes following the first dose. This may be owing to a more rapid absorption from the granules formulation in these patients and/or a local action of ibuprofen in solution in the mouth.

CONCLUSION

The effervescent soluble form of ibuprofen (Brufen Granules) is preferable to the conventional tablet form in managing the immediate dental pain experienced post-operatively by most patients because of its faster onset of action.

Tailoring nicotine addiction treatments for chemical dependency patients

The growing scientific evidence for addressing nicotine addiction in chemical dependency (CD) treatment programs is reviewed. This evidence provided the impetus for a survey of smoking patterns and quitting motivation and barriers among CD patients to identify ways to tailor standard nicotine addiction treatment methods and goals to their needs. Smoking history questionnaires were administered to 118 consecutive patients in a residential CD treatment program. The 66% of patients who smoked were predominantly heavy smokers, highly addicted (mean 25 cigarettes per day, 76% smoking within 30 minutes of waking). Although 63% of patients were "precontemplators," most of the sample had a history of one or more serious quit attempts, most reported strong beliefs in smoking harms and quitting benefits, and almost half reported a strong desire to stop smoking. Major quitting barriers included the usual psychological and physical sequelae of tobacco abstinence in addition to being around other smokers. Surprisingly, very few patients expressed concerns that quitting smoking would threaten drug or alcohol sobriety. Treatment implications are discussed. In addition, a pilot 4-session group treatment program is described. This program was geared to motivating smokers in "precontemplation" and "contemplation" stages of change to move ahead into the "action" stage (i.e., taking steps to quit).

A whole blood control for blood count analysers, and source material for an external quality assessment scheme

An inexpensive and simple to prepare stable whole blood control material for blood count analysers has been evaluated. The material has been used for an external quality assessment scheme for 3 years, and during part of this period as a calibrant for two aperture impedance devices.

Squamous cell cancer of the larynx in an intravenous drug user with AIDS

We present the case of a 29-year-old intravenous drug user with AIDS and squamous cell cancer of the larynx. Profound immunosuppression was evident by an OKT4:OKT8 ratio of 0.1. Simultaneous treatment of the laryngeal cancer by laser vaporization and treatment of immunosuppression with zidovudine resulted in no tumor recurrence after one year.