NEJM 30 Nov 2006

When I was ten, I got the fattest book I could out of the city library, Mellor’s Modern Inorganic Chemistry. To my surprise I found that I could follow most of it and that it explained everything about how stuff came to be the way it is. Moreover it was spiced with accounts of nasty diseases caused by chemicals, such as phossy-jaw in phosphorus workers. It became my favourite reading for about a year, though Biggles often intervened. Now, phossy-jaw died out long ago as an industrial disease, but osteonecrosis of the jaw due to bisphosphonates has recently been widely reported. Since we now prescribe these drugs to half our elderly women, are we about to witness a jaw-dropping epidemic? The short account here is reassuring. Nearly all cases of modern phossy-jaw follow the administration of intravenous bisphosphonates for myeloma or metastatic breast cancer. Poor dental hygiene or dental surgery seem to be risk factors.

Although HIV is a central challenge to modern therapeutics, I tend not to comment about it as we GPs leave its management to experts, and few of us know our lamivudine from our efavirenz. Nor do we know how best to use these drugs in the long term – and to some extent, that ignorance is shared by the experts. For example, might it be a SMART idea to give patients the occasional holiday from anti-retroviral treatment? Quite the opposite, say the Strategies for Management of AntiRetroviral Therapy investigators; break off at your peril, since the group who had episodic treatment guided by CD4+ count fared worse.

A fatty liver is generally associated with insulin resistance, and non-alcoholic steatohepatitis (NASH) also often involves death and inflammation of liver cells. We know that thiazolidinediones like pioglitazone improve glucose metabolism in type 2 diabetes, so might they do the same in NASH? This preliminary study shows that this does happen, and that the pioglitazone group also showed less progression of liver damage. More and bigger trials will follow. But beware of inducing heart failure with these drugs.

Another week, another paper from Harlan Krumholz. Behold, he that keepeth America shall not slumber nor sleep. Here his team tries to work out the best way to preserve people from the smitings of acute myocardial infarction by reducing door-to-balloon time. They identify six strategies, all pretty obvious things to do with getting catheter labs ready and staffed, but find that only a minority of hospitals use them. Any lessons for the NHS?

Rarely does a day go by in general practice without some attempt to treat menopausal symptoms. One of the main symptoms is what we call flushes, and which the Americans call flashes: “I say flush, you say flash, let’s call the whole thing off