Framework research programme

for initial therapy. In addition, health worker education has improved TB surveillance and patients’ Tuberculosis (TB) incidence fell 15% in therapy increased more than tenfold ’., isolation in hospitals and prisons, where New York City last year, the first annual between 1988 and 1993, and during this outbreaks of multi-drug resistant strains decrease since 1984. Public health offiperiod patients’ visits to the expanding have occurred for several years. cials attribute the decline to expanded system of free municipal TB clinics The federal government stopped fundtreatment and control programmes made quadrupled. The city also began a controing TB control in 1972, but resumed a affordable by renewed government fund- 1 versial confinement programme, but thus decade later. At that time, the city ing. There were 3235 new cases in 1993, far only 25 patients have been compelled received$160 000 and the case rate was making the citywide case-rate 44 per to enter (see Lancet 1992; 340: 1459). 22. Last year Washington sent New York 100 000 population. Although this is the Citing the combination of their measures, $25 million and successfully limited the lowest rate since 1989, in some neighofficials are pleased that between 1988 rate to twice the value it was a decade earbourhoods-and among certain groupsand 1993, the percentage of patients com- : lier. "If you spend resources appropriately rates are more than twenty to forty five pleting TB therapy went up from 50% to on things that we know will work for TB times the national average. In central 75%. New York has also made changes in control", said Dr Thomas R Freiden, Harlem for example, the rate is 222, and TB diagnosis and treatment. Since 1991, Director of the New York Department of among young African-American men it is the city has required central reporting of Health Bureau of Tuberculosis Control, 454. : all drug susceptibility tests on TB isolates, "you can control TB. It is a winnable The New York TB strategy is directed and patients with newly diagnosed infecdisease" primarily to patient compliance. The tion are routinely prescribed four drugs t number of patients on directly observed (isoniazid, rifampin, ethambutol, and David Frankel

Tuberculosis decreases In New York

Unstable angina

guidelines in the USA

pyrazinamide)

Framework research

programme aspirin because of a history of true hypersensitivity or recent significant gastroin- The European Parliament has won its testinal bleeding. Newly diagnosed angina fight to get the proposed budget for the patients can be started on sublingual glyc- European Union Framework Research eryl trinitrate, followed by beta-blockers Programme raised from the 12 billion and/or long acting nitrates. : ECU that the Council of Ministers had The panel estimated that approximately At special Parliament-Council half the patients presenting with unstable agreed. conciliation talks on Monday March 21 angina fall into this low-risk category and both sides agreed to a new global budget completed can be sent home. Their follow-up evalua- of 12-3 billion ECU that was only 100 tion, however, should be prompt, prefermillion ECU less than the sum the Parliaemergency department. : ably within 72 h. Moderate and high risk ment wanted. The Council also agreed All patients suspected of having unsta: that by June 30, 1996, it would decide patients should be admitted to hospital. ble angina should receive aspirin unless : If a patient’s symptoms recur after the whether to increase the by a furthey have contraindications. Patients who goals of haemodynamic therapy have been ther 700 million ECU. budget Half the extra have ongoing pain or abdominal electro- ireached, urgent cardiac catheterisation will go to specific research proshould be considered, the panel said.1 money cardiograms should also be treated with 40% on international aid, and glyceryl trinitrate, beta-blockers, and Patients who have "one or more recur- grammes, the remainder on diffusion and assessintravenous heparin while they are still in rent, severe, prolonged (>20 min) ment of results. Two-thirds of the Parliathe emergency department. "Medical ischemic episodes, particularly when ment must now back the change in therapy should not wait until the patient is : accompanied by pulmonary edema, new next month for it to go ahead. admitted to the hospital", the panel said. or worsening mitral regurgitation mur- Strasbourg The panel recommended that calcium ’, mur, hypotension, or new ST- or T-wave Sara Lewis channel blockers not be a first-line thera- changes" should be assigned to the highrisk category and triaged to early cardiac py, unless the patient is unresponsive to beta-blockers and glyceryl trinitrate or has : Bulgarian health catheterisation, the panel said. variant angina. "Intravenous thrombolytic: In most severe forms of coronary artery The latest figures from Bulgaria’s disease, coronary artery bypass grafting therapy is not indicated in patients who do not have evidence of acute ST-segment National Health Information Centre show provides the best long-term survival elevation or left bundle block on their 12- results and should be recommended for that respiratory diseases account for some lead ECG", the panel said. almost all patients with left main disease30% of all diseases recorded each year, Unstable angina patients who are free and many patients with three-vessel dis- and 5% of all deaths. Official antismoking of pain and who are considered to be at ease, especially those with left ventricular i campaigns tend to be low-key, and even low risk of death or myocardial infarction dysfunction, the panel said. :in the 1980s, it was a common sight to see in the short term can be sent home, the hospital patients smoking without any these are said. rebuke or caution from the medical staff. patients panel "Typically who have experienced new onset or worsMichael McCarthy This is because Bulgaria is an important tobacco grower. In both the agricultural ening symptoms that may be due to ischemia, but they have not had severe, decline of the last socialist years and the 1 Braunwald E, Mark DB, Jones RH, et al. confusion of post-socialist reconstruction, Clinical practice guideline, unstable angina: prolonged, or rest episodes in the preceddiagnosis and management. AHCPR government economists have been unening 2 weeks". The panel recommended publication no 94-0602. Rockville, MD, US thusiastic (to say the least) about anything that these patients be prescribed aspirin Department of Health and Human Services, that might cause severe setbacks in a key 80 to 325 mg per day unless contraindiPublic Health Service, Agency for Health cations are present. Ticlopidine 250 mg industry. Care Policy and Research and National twice a day can be used as a substitute for Heart Lung and Blood Institute. March Vera Rich 1994. aspirin in those patients who cannot take

Evaluation of patients with unstable angina should be prompt and their treatment swift, according to guidelines issued on March 15 by the US Public Health Service’s Agency for Health Care Policy and Research.1 : The panel, which was led by Dr Eugene: Braunwald MD, said that the initial evaluation of a patient with symptoms suggestive of unstable angina be within 1 h of the patient’s arrival in the

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