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Nicotine withdrawal impairs attention
Family history helps predict risk of sudden death
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prospective study of more than 20-years duration has shown that parental sudden death is a clear predisposing factor for sudden death in middle-aged men. The Paris Prospective Study I followed 7746 Frenchmen, aged 43–52 years, between 1962 and 1994. “Participants were examined phys ically at the start of the trial and were asked if either of their parents had a history of myocardial infarc tion and whether their death was sudden”, explains lead author Xavier Jouven (Hôpital Boucicaut and INSERM V258, Paris, France). The research team obtained a list of participants who died each year and recorded the cause of each death. Sudden death was defined as a natural death occurring within an hour of the onset of acute symp toms. Of the 7079 men followed up, 2083 died during the 23 years of the trial. 603 deaths were a result of cardiovascular causes: 19·6% sud den deaths, 31·8% fatal myocardial infarctions, 5·1% cardiac failure, 18·2% other cardiac causes, 16·6%
strokes, and 8·6% other vascular incidents. 18·6% of those in the sudden-death group had a parent who also died suddenly. 9·9% of patients who died from myocardial infarction and 10·6% who died of other causes reported a history of parental sudden death ( Circulation 1999; 99: 1978–83). Jouven concludes that the relative risk for sudden death if one parent has died suddenly is 1·89 and the relative risk of sudden death if both parents have died suddenly is 9·44. “This is a significant marker of sudden-death risk that can be used to identify individuals and popula tion groups that would benefit from greater risk-factor management.” Joseph Alpert (Department of Clinical Cardiology, University of Arizona, Tucson, AZ, USA) agrees and considers the results of the study “valid and interesting. Since we know of several genetic disor ders that predispose to sudden death, the association shown is not surprising”, he comments. Kathryn Senior
Nicotine withdrawal impairs attention
T
task”. Smoking after abstinence he cognitive impairment that improved the impaired responses in affects people who quit smoking the former test to baseline values, is often given as a reason for relapse. and enhanced performance of the Now, a team led by Stephen logical-reasoning test (Nicotine & Heishman (National Institute on Tobacco Research 1999; 1 : 45–52). Drug Abuse, Baltimore, MD, USA) “It’s our ability is beginning to to concentrate identify the spethat seems to cific mental funcbe most readily tions affected by impaired in early nicotine withnicotine withdrawal. drawal”, explains Heishman and Heishman. So to colleagues asked help smokers 20 long-term quit, “we need to smokers to do focus on ways two tests: a letterto alleviate attensearch task to A dangerous aid to concentration tional deficits”, measure basic —eg, with nicotine patches or attentional processes; and a logicalgum. And before people reach for reasoning task to measure complex, cigarettes to help them think faster, cognitive functioning. Tests were Heishman warns that “there is not a done before and after smoking two lot of strong evidence for nicotine cigarettes—one session took place enhancement of memory and cogniwhen the volunteers had been smoktion in healthy people”. This seems ing as usual; the second occurred to occur only when a person is after 18 hours abstinence. deprived or impaired in some way, The team hypothesised that abstisuch as during nicotine withdrawal nence would affect performance in or in memory disorders, he adds. both tests, but, says Heishman, “we saw impairment on the letter-search test but not on the logical-reasoning Kelly Morris
THE LANCET • Vol 353 • April 24, 1999
Aiming for good pain care in terminal cancer
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ost patients dying of cancer can be given effective pain relief in their own homes if WHO guidelines on controlling cancer pain are followed, says palliative-care specialist Sebastiano Mercadante (Buccheri La Feria Fatebenefratelli Hospital, Palermo, Italy). In an open, prospective study in more than 3600 patients with advanced cancer, Mercadante found that pain was reduced to tolerable levels with acceptable symptom intensity “in almost all” of the 70% who needed analgesic treatment during the last weeks of life (Cancer 1999; 8 5 : 1849–58). “This was achieved in a short time and for prolonged periods in the presence of different pain mechanisms and in the patients’ own homes”, he says. WHO guidelines for palliative care in cancer recommend a three-step sequence of analgesic medication, starting with non-opioid analgesics and guided by the intensity of the patient’s pain. Adjuvant drugs—eg, co-analgesics, laxatives, antiemetics, antiulcer drugs—are used as needed. Mercadante’s regimen began with a non-steroidal anti-inflammatory drug, to which a medium-potency opiate (MPO) was added if pain relief was inadequate. Strong opioids were used in step three, with dose escalation or alternative opioids if required. Patients were managed at home with help from a palliative-care team. In the last week of life, 16%, 49%, and 35% of patients were taking nonopioid drugs, MPOs, and strong opioids, respectively. “Undertreatment of cancer pain persists despite efforts to provide clinicians with information regarding the use of analgesics”, says Mercadante. “When there is no longer the capability to prolong life, medicine can instead be used quite effectively to control pain. It is a simple matter of following WHO’s guidelines and listening to our patients.” “Oncologists in training need formal instruction in the use of the WHO pain guidelines and evaluations to make sure that they use these interventions appropriately in caring for terminally ill cancer patients”, says oncologist Ezekial Emanuel (US National Institutes of Health Clinical Center, Bethesda, MD, USA). “The study also suggests that all oncologists should have available a palliative-care team”, he adds. Dorothy Bonn
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A
prospective study of more than 20-years duration has shown that parental sudden death is a clear predisposing factor for sudden death in middle-aged men. The Paris Prospective Study I followed 7746 Frenchmen, aged 43–52 years, between 1962 and 1994. “Participants were examined phys ically at the start of the trial and were asked if either of their parents had a history of myocardial infarc tion and whether their death was sudden”, explains lead author Xavier Jouven (Hôpital Boucicaut and INSERM V258, Paris, France). The research team obtained a list of participants who died each year and recorded the cause of each death. Sudden death was defined as a natural death occurring within an hour of the onset of acute symp toms. Of the 7079 men followed up, 2083 died during the 23 years of the trial. 603 deaths were a result of cardiovascular causes: 19·6% sud den deaths, 31·8% fatal myocardial infarctions, 5·1% cardiac failure, 18·2% other cardiac causes, 16·6%
strokes, and 8·6% other vascular incidents. 18·6% of those in the sudden-death group had a parent who also died suddenly. 9·9% of patients who died from myocardial infarction and 10·6% who died of other causes reported a history of parental sudden death ( Circulation 1999; 99: 1978–83). Jouven concludes that the relative risk for sudden death if one parent has died suddenly is 1·89 and the relative risk of sudden death if both parents have died suddenly is 9·44. “This is a significant marker of sudden-death risk that can be used to identify individuals and popula tion groups that would benefit from greater risk-factor management.” Joseph Alpert (Department of Clinical Cardiology, University of Arizona, Tucson, AZ, USA) agrees and considers the results of the study “valid and interesting. Since we know of several genetic disor ders that predispose to sudden death, the association shown is not surprising”, he comments. Kathryn Senior
Nicotine withdrawal impairs attention
T
task”. Smoking after abstinence he cognitive impairment that improved the impaired responses in affects people who quit smoking the former test to baseline values, is often given as a reason for relapse. and enhanced performance of the Now, a team led by Stephen logical-reasoning test (Nicotine & Heishman (National Institute on Tobacco Research 1999; 1 : 45–52). Drug Abuse, Baltimore, MD, USA) “It’s our ability is beginning to to concentrate identify the spethat seems to cific mental funcbe most readily tions affected by impaired in early nicotine withnicotine withdrawal. drawal”, explains Heishman and Heishman. So to colleagues asked help smokers 20 long-term quit, “we need to smokers to do focus on ways two tests: a letterto alleviate attensearch task to A dangerous aid to concentration tional deficits”, measure basic —eg, with nicotine patches or attentional processes; and a logicalgum. And before people reach for reasoning task to measure complex, cigarettes to help them think faster, cognitive functioning. Tests were Heishman warns that “there is not a done before and after smoking two lot of strong evidence for nicotine cigarettes—one session took place enhancement of memory and cogniwhen the volunteers had been smoktion in healthy people”. This seems ing as usual; the second occurred to occur only when a person is after 18 hours abstinence. deprived or impaired in some way, The team hypothesised that abstisuch as during nicotine withdrawal nence would affect performance in or in memory disorders, he adds. both tests, but, says Heishman, “we saw impairment on the letter-search test but not on the logical-reasoning Kelly Morris
THE LANCET • Vol 353 • April 24, 1999
Aiming for good pain care in terminal cancer
M
ost patients dying of cancer can be given effective pain relief in their own homes if WHO guidelines on controlling cancer pain are followed, says palliative-care specialist Sebastiano Mercadante (Buccheri La Feria Fatebenefratelli Hospital, Palermo, Italy). In an open, prospective study in more than 3600 patients with advanced cancer, Mercadante found that pain was reduced to tolerable levels with acceptable symptom intensity “in almost all” of the 70% who needed analgesic treatment during the last weeks of life (Cancer 1999; 8 5 : 1849–58). “This was achieved in a short time and for prolonged periods in the presence of different pain mechanisms and in the patients’ own homes”, he says. WHO guidelines for palliative care in cancer recommend a three-step sequence of analgesic medication, starting with non-opioid analgesics and guided by the intensity of the patient’s pain. Adjuvant drugs—eg, co-analgesics, laxatives, antiemetics, antiulcer drugs—are used as needed. Mercadante’s regimen began with a non-steroidal anti-inflammatory drug, to which a medium-potency opiate (MPO) was added if pain relief was inadequate. Strong opioids were used in step three, with dose escalation or alternative opioids if required. Patients were managed at home with help from a palliative-care team. In the last week of life, 16%, 49%, and 35% of patients were taking nonopioid drugs, MPOs, and strong opioids, respectively. “Undertreatment of cancer pain persists despite efforts to provide clinicians with information regarding the use of analgesics”, says Mercadante. “When there is no longer the capability to prolong life, medicine can instead be used quite effectively to control pain. It is a simple matter of following WHO’s guidelines and listening to our patients.” “Oncologists in training need formal instruction in the use of the WHO pain guidelines and evaluations to make sure that they use these interventions appropriately in caring for terminally ill cancer patients”, says oncologist Ezekial Emanuel (US National Institutes of Health Clinical Center, Bethesda, MD, USA). “The study also suggests that all oncologists should have available a palliative-care team”, he adds. Dorothy Bonn
1419