1-23 PROPHYLAXIS OF VENOUS THROMBOSIS
1-24 HELICOBACTER PYLORI INFECTION
1-25 INSULIN ANALOGUES
1-26 NURTITIONAL SUPPORT
1-27 RECOMMENDED READING

THE SUPREME COURT AND PHYSICIAN-ASSISTEDSUICIDE—THE ULTIMATE RIGHT See abstract 1=13

COMPETENT CARE OF THE DYING INSTEAD OF PHYSICIAN-ASSISTED SUICIDE See abstract 1-14

POLYMERASE CHAIN REACTION
A brief description BMJJanuary 4, 1997; 314: 5-5

REFERENCE ARTICLES

I believe a collection of good, up-to-date narrative review articles published in the flagship journals can be the primary-care physicians’ best source of "Evidence-based Medicine". They are well edited, peer reviewed, condensed, updated periodically, and contain clinical relevant information. It is not difficult to assemble a collection for ready reference. RTJ

1-23 PROPHYLAXIS OF VENOUS THROMBOSIS
Objective diagnostic measures have shown that, without antithrombotic prophylaxis, 8-1 of patients develop venous thrombosis after major general surgery, 36-60% after surgery for hip fracture, 47-57% after total hip replacement, and 40-80% after total knee replacement.
The only way to prevent fatal and non-fatal pulmonary embolism effectively is to prevent proximal vein thrombosis.
Deep vein thrombosis is also important because it can cause serious morbidity from chronic venous insufficiency. About 50% of patients with symptomatic proximal vein thrombosis develop the post-phlebitic syndrome 5 to 7 years later.
This article presents risk factors for venous thromboembolism (background factors and disease or surgical procedures) which increase risk; a classification of low risk, medium risk, and high risk of proximal vein thrombosis; and recommended preventive treatment. (Graduated elastic compression stockings and low-molecular weight heparin are recommended.)
BMJ January 11, 1997; 314: 123-25 review article from Centre for Molecular and Vascular Biology, Leuven, Belgium

1-24 HELICOBACTER PYLORI INFECTION
This concise review comments on diagnosis, treatment of ulcers and dyspepsia, epidemiology, and pathogenesis.
Lancet January 25, 1997; 349: 265-69 Seminar from St. Georges Hospital Medical School, London

1-25 INSULIN ANALOGUES
This editorial comments on the new insulins made by exchanging two amino acids in the B chain.
The insulin homologue, insulin-like growth factor I, exists as a monomer with lysine at B28 and proline at B29. This is opposite to that of human insulin.
When the amino acid switch is made in the human insulin molecule, forming insulin lispro, it leads to faster absorption. The onset of action is within 15 minutes rather than the 30-45 minutes with soluble human insulin. Duration of action is shorter (about 5 vs 8-12 hours).
Patients prefer an insulin that can be given nearer meal time. Whether this leads to better control as measured by HbA1c is debatable.
Presently the authors do not advise that insulin lispro should be initiated in primary care.
Lancet January 4, 1997; 349: 47-50 "Drug Profile", first author from Univ. Of Birmingham, UK

1-26 NUTRITIONAL SUPPORT
The simplest way to screen patients for malnutrition is to ask them about unintentional weight loss.
The article comments on: 1) identification of malnourished patients; 2) indications for nutritional support (major elective surgery, major trauma, bone marrow transplantation); 3) optimal route of delivery and composition of nutritional formulas (enteral route is preferred); 4) benefits and costs.
Glutamine supplements may be beneficial in selected groups of patients.
NEJM January 2. 1997; 336: 41-48 review article from Massachusetts General Hospital, Boston

RECOMMENDED READING

Some articles carry important messages but are difficult to abstract. Some are controversial. All are provocative. They should be read in their entirety. I clip and save them in a separate folder. I will try to include brief quotations from time to time. RTJ

THE SUPREME COURT AND PHYSICIAN-ASSISSTED SUICDE — THE ULTIMATE RIGHT
See abstract 1-13

COMPETENT CARE OF THE DYING INSTEAD OF PHYSICIAN-ASSISTED SUICIDE
See abstract 1-14

POLYMERASE CHAIN REACTION
A brief description BMJ January 4 1997: 314:5-6

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