RECOMMENDED READING
3-1 WRITING PRESCRIPTIONS IS EASY
3-20 LAPAROSCOPIC SURGERY
Concordance, not compliance. Read the original!

3-18 TREATMENT OF BACTERIAL MENINGITIS: EPIDEMIOLOGIC TRENDS
The frequency of meningitis due to H influenzae in children has declined dramatically because of widespread vaccination. S pneumoniae and N meningitis have become the predominant causes.Emergence of penicillin resistant strains of S pneumoniae causes concern. Now, strains resistant to cefotaxime are appearing.

Principles of Therapy:
Optimal antibiotic treatment requires that the drug have a bactericidal effect in the cerebrospinal fluid in high concentration. Achieving this rapidly is primary goal. Only patients with coma, papilledema, or focal neurological signs require cranial computed tomography before lumbar puncture.

Empirical Selection of Antibiotic:
(Table 2p. 711)
Empirical Glucocorticoid Therapy:
"We recommend adjunctive dexamethasone therapy in children more than 2 months of age.
Pathogen Specific Therapy:
S pneumoniae, H influenzae, N meningitis and less common pathogens (pp 711-13).

NEJM March 6, 1997; 336: 708-15 Review article, first author from Yale Univ. School of Medicine, New Haven, Conn.

3-19 LEGAL ASPECTS OF THE DEMENTIAS
If a demented person refuses care necessary to survive or maintain capacity for essential functioning, or demands treatment jeopardizing these interests, the principle that patient’s wishes prevail over their interests is suspended in favor of a guardian’s protective duties.
Removal of demented patient’s driving licenses may not constitute unlawful discrimination, even when they are capable of mechanical operation of a vehicle. Driving is a privilege granted by license. The license may be removed for protective reasons when holders are at risk of becoming confused, disoriented, or indecisive when prompt decision-making is required.
When competent people anticipating disability say in advance that they would decline particular treatments, such as life-prolonging interventions if they become persistently vegetative, their statements may be held operative in the circumstances they anticipate.
"Statements need not be in any special form to have legal effect, but a limit is that, while they are effective to decline indicated care, they are not effective to compel medically inappropriate...care."
Lancet March 29, 1997; 349: 948-50 Commentary from a JD, Univ. Of Toronto, Canada

Comment:
This is a Canadian view. I believe the principles apply also to the US. RTJ

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

3-20 LAPAROSCOPIC SURGERY
This review article classifies laparoscopic procedures. (There have been 43 different operations for which laparoscopic, or laparoscopically assisted, approaches have been tried.)
After reviewing evidence of effectiveness, the reviewer concludes that laparoscopic surgery, in terms of patient outcome and overall management of abdominal disease, has been a very small advance after a huge financial investment. Only cholecystectomy has become an acceptable alternative for a small incision approach.
"Laparoscopic surgery is not easier, quicker, cheaper, or safer; nor does it avoid a general anesthetic. It may lead to a slightly shorter initial hospital stay, but readmissions for complications and other procedures have to be added."
Lancet March 1, 1997; 349: 631-35 Seminar from Univ. Of Sheffield, UK
Comment: This is a British view. RTJ

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