Clinical nutrition
Severe protein–energy malnutrition occurs in at least 25% of patients in hospital. This starvation state can result in muscle wasting, reduced cardiac and respiratory muscle capacity, thinning of skin, hypothermia, edema, immunodeficiency and a decreased metabolic rate. In the first article of our new series on clinical nutrition, John Hoffer reviews the pathophysiology of the protein–energy malnutrition state and examines the clinical parameters recognized in the subjective global assessment. Practical suggestions for the treatment of affected patients are outlined, including an emphasis on oral nutrition.
See pages 1343 and 1345
Autoimmune obsessive–compulsive disorder
The cause of obsessive–compulsive disorder (OCD) is unknown. Paul Arnold and Margaret Richter review a subtype of OCD known as “pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections” (PANDAS). The authors discuss the possibility of antistreptococcal antibodies cross-reacting with the basal ganglia in the brain and causing the often disabling neuropsychiatric symptoms of OCD. An approach to the diagnosis and management of PANDAS is discussed.
See page 1353
Beyond LDL cholesterol
The widely adopted Framingham algorithm, which helps clinicians calculate the cholesterol targets for people with different cardiac risk factors, may be inadequate for determining a person's risk of coronary artery disease (CAD). Jean-Pierre Després and coauthors have reviewed how individuals with a normal low-density lipoprotein (LDL) cholesterol level can still be at increased risk of CAD, particularly if they carry additional risk factors such as central obesity, elevated serum triglyceride levels and insulin resistance. In such people, a better marker for increased CAD risk may be an elevated total cholesterol:high-density lipoprotein (HDL) cholesterol ratio. Thus, even if such a person's LDL cholesterol level is considered acceptable, the authors recommend targeting the causal factors of this atherogenic dyslipidemia, including abdominal obesity.
See page 1331
Smallpox
As recently as 1967 smallpox was responsible for 2 million deaths per year, but worldwide vaccination programs successfully eradicated the endemic organism in the late 1970s. In the wake of the events on Sept. 11, the possibility has been raised of the use of smallpox as a bioterrorism agent. Erica Weir discusses the clinical course of smallpox infection and the public health perspective on the clinical management of an outbreak.
See page 1380 See also The Left Atrium page 1364
Headache after cervical or lumbar puncture
Does bed rest prevent headache after cervical or lumbar puncture? Jana Thoennissen and coauthors conducted a systematic review and meta-analysis to help answer this question. They identified 16 randomized controlled trials involving 1083 patients assigned to immediate mobilization or short bed rest (up to 8 hours) and 1128 patients assigned to a longer period of bed rest (0.5 to 24 hours). Because of clinical heterogeneity in the trials, the authors were forced to group the studies according to the reason for the procedure (anesthesia, myelography or diagnosis). Regardless of the reason for puncture, they found no evidence that longer bed rest was better at reducing the incidence of headache after puncture than immediate mobilization or shorter periods of bed rest.
See page 1311