There are several high-level guidelines available for the treatment of acute exacerbations of COPD. The recommendations include nebulized salbutamol ± ipratropium, oral corticosteroid, and pulmonary education and rehabilitation.

Antibiotic therapy is not routine, but should be considered with increased sputum volume, and non-invasive positive pressure ventilation (NIPPV) should be considered in all patients with pH <7.35 and respiratory rate >30.

In selected cases, the use of long-term oxygen therapy improves survival. On the other hand, most guidelines advise against the use of intravenous aminophylline. A recent paper from Melbourne reports on an audit on the management of 84 such patients. They report that recommendations for steroid initiation and avoidance of aminophylline were well used but concordance rates for other recommendations were generally less than 60%.

It has long been recognised that there is an association between cancer and venous thrombosis—in fact it was first documented by Trousseau in 1868. A recent study from the Netherlands tries to quantify and qualify this important subject.

In this large case-control study of venous thrombosis, they found that there was a seven-fold increased risk for venous thrombosis in patients with a malignancy. Gastrointestinal cancer, lung cancer, and hematological cancer were the malignancies associated with the greatest relative risk and, unsurprisingly, the more advanced the disease, the greater the risk. The risk is approximately 12- o 17-fold increased for patients with cancer who have the factor V Leiden or the prothrombin 20210A mutation.

The authors conclude that rather than screening for these factors “it may be more cost-effective to consider prophylactic anticoagulant therapy for patients with cancer who have an increased risk to develop venous thrombosis.”

Coronary artery stenting has revolutionised the management of ischaemic heart disease. However restenosis is a major limitation to long-term success, and it is estimated that 14% of patients who undergo stent implantation require a second intervention within a year to manage restenosis. Could this be overcome by the use of drug-eluting stents?

Sirolimus, a macrolide antibiotic with immunosuppressive and antimitotic properties, was found to be potent in reducing the restenosis incidence from 35.4% to 3.2%. So why not use sirolimus-eluting stents routinely?

You know the answer—too expensive. Three papers in the Canadian Medical Journal tackle this problem. Their conclusions—a split vote.

Now, however, George Bush has announced that he is to ask Congress to impose strict limits on medical malpractice lawsuits, saying that doctors “should be focused on fighting illnesses, not on fighting lawsuits.” He has proposed that Congress should set a limit of $US250,000 for non-economic damages, such as “pain and suffering.” As the Republicans have a Senate majority it may even happen.

But, the immediate past president of the American Medical Association has pointed out that most medical liability claims—almost 70%—do not result in any payments but still cost an average of US$90,000 to defend sucessfully.

Why don’t antibiotics eradicate all bacterial infections? Because they can’t get into the biofilm. The what? A biofilm is a community of microorganisms that are associated with a surface and typically enveloped in an extracellular matrix. Apparently they’re everywhere, e.g. the plaque on human teeth—that’s why the dentist likes to scrape it off.

More importantly, biofilm-associated infections are related to biomaterials and implants, such as infection associated with intravascular catheters and prosthetic-valve endocarditis. And we all know how the orthopaedic surgeons fear infection in their joint implants. So bacterial biofilm is a major problem. At the frontline, we can all help by minimising the risks of dubiously needed intravenous and bladder catheters.