Lancet 10 Mar 2007 Vol 369

Innumerable trials and systematic reviews over the last decade have pressed home the message that early invasive treatment is best for acute coronary syndromes. Now the best marker for cell damage in ACS is elevation of troponins, but these do not peak for half a day or more and so immediate treatment still has to be guided by ST elevation. The ICTUS trial looked specifically at non-STE-ACS and found benefit from immediate invasive treatment only in patients with high troponins, as you might expect. But it’s not clear to me how thisinformation helps clinicians in the first few hours.

In my childhood, asbestos was regarded as a wonderful material and used everywhere. Men in asbestos suits were sent into the massive fireboxes of huge American express steam locomotives to clear them out and provide turn-round times to compete with diesel engines. Everything (including steam locomotives) was lagged with asbestos. It was used to filter beer. Builders used to chew it and use it as a filler. Asbestos roofing covered every shed and council house. Then pleural and peritoneal mesothelioma started appearing wherever asbestos had been used, and the fatal epidemic continues in proportion to its previous use in different countries, as illustrated in this paper.

There was once a time when national leaders who had done great crimes were made to do public penance, like King Henry II who walked in sackcloth and ashes to Becket’s tomb in Canterbury, and was publicly flogged in the cathedral square at Avranches. Tony Blair, one suspects, is not about to follow suit, but would like to get away with promises about reduced carbon emissions and global health. I think he should go and work in an Iraqi hospital.