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Raise your hands if you are fainting
THE LANCET 4
5
Maley W.The dynamics of regime transition in Afghanistan. Central Asian Survey 1997; 16: 167–84. Maley W.Women and public policy in Afghanistan: a comment. World Devel 1996; 24: 203–06.
Decline in mortality from testicular cancer in West Germany after reunification
Standard mortality rate (per 100 000 people)
SIR—Testicular cancer is one of the most curable adult solid tumours with the demonstrated efficacy of treatment in clinical trials1 brought to bear on entire populations in which the gap between increasing incidence and decreasing mortality is gradually widening.2 P Boyle and colleagues3 pointed out that the dramatic decline in mortality from testicular cancer seen in many developed countries was not present in central and eastern Europe because of the lack of financial resources to purchase the expensive drugs necessary to treat disseminated testicular cancer. The economic situation in the countries of central and eastern Europe has undergone radical change together with major changes in health care.4 For example, economic improvement and the establishment of a central treatment centre has been successful in reducing mortality from testicular cancer in Slovakia.5 Since 1980, mortality data from the former German Democratic Republic (GDR) has been available. Of all the former territories of central and eastern Europe, arguably the most sudden and notable change took place here. In the former Federal Republic of Germany (FRG), the mortality rate of testicular cancer peaked in the mid 1970s; by 1995, the mortality rate (0·4 per 100 000 people) was less than onethird of that in 1977 (1·4 per 100 000 people). By contrast, in the former GDR, the mortality rate did not change until the opening of the border in 1989 (1·5 per 100 000 people) and has substantially declined by 50% (figure). The current mortality rate (0·7 per 100 000 people) is slightly higher in the territories of former GDR than that in former FRG (0·4 per 100 000 people). The decline in mortality from testicular cancer in the former GDR has 2·0 1·8 1·6 1·4 1·2 1·0 0·8 0·6 0·4 0·2 0
West Germany East Germany 95 19 0 9 19 5 8 19 0 8 19 5 7 19 0 7 19 5 6 19 0 6 19 5 5 19 0 5 19
Year Secular trend of mortality for malignant neoplasm of testis (ICD 186)
744
paralleled the economic changes after German reunification and lends support to the hypothesis that economic factors had previously limited the implementation of new treatment for this curable cancer. *Nikolaus Becker, Peter Boyle *Division of Epidemiology, Cancer Prevention Unit, Deutsches Krebsforschungszentrum, D 69120 Heidelberg, Germany; and Division of Epidemiology and Biostatistics, European Institute of Oncology, Milan, Italy
1
2
3
4
5
Einhorn LH, Donohue JP. Cisdiamminedichloroplatinum, vinblastine and bleomycin combination chemotherapy in disseminated testicular cancer. Ann Intern Med 1977; 87: 293–99. Boyle P, Kaye SB, Robertson AG. Changes in testicular cancer in Scotland. Eur J Cancer Clin Oncol 1987; 23: 827–30. Boyle P, Maissonneuve P, Kaye SB.Testicular cancer in Central Europe. Lancet 1990; 335: 1033, Zatonski WA, Boyle P. Health transformations in Poland after 1988. J Epidemiol Biostat 1996; 1: 183–97. Plesko I, Ondrus D, Boyle P. Evolution of testicular cancer incidence and mortality in Slovakia, 1968–1990. Lancet 1996; 347: 900–01.
Raise your hands if you are fainting SIR—Giraffes do not raise their heads abruptly, they would faint if they did. A column of blood in their neck exerts a pressure of about 120 mm Hg and central arterial pressure cannot instantly increase by this amount as it should to prevent cerebral perfusion from dropping.1 This type of postural hypotension (a fact lions must be aware of) is normal among giraffes. Imagine now that they had a trunk like the elephant. Could they avoid fainting by thrusting their proboscis in the air before quickly raising their head? Human beings with orthostatic hypotension, it seems, can do so with their arms. Measures recommended for postural hypotension include: compression of veins in the lower extremities (exercising leg muscles, wearing tight stockings); expansion of extracellular volume (highsalt diet, salt-retaining steroids); treatment with sympathomimetic amines (eg, ephedrine);2 and abdominal compression.3 Might raising the arms, a simple manoeuvre hitherto not reported, be added to them, as the following case report suggests? An otherwise healthy man aged 42 years who was taking no drugs and had a history of mild postural hypotension (occasional transient dizziness and nearsyncope on arising from sitting, squatting, or recumbency) was told to lie in a hot bath for 15 min and, to precipitate symptoms, to stand up rapidly, either with his arms raised, keeping them up for 15 s or after repeated exercising of his leg muscles
(20 foot flexions and extensions and standing on and off his toes once upright). He stood up six times with intervals of 5 min on each of three days. Dizziness or near-fainting was invariably reported instantly or within seconds of standing up after exercising his legs, but did not occur when his arms were raised. In the latter posture he always reported a distinct awareness of his radial pulses. His heart rate increased slightly in both positions. Since then, in situations that cause him postural hypotension, he successfully uses this manoeuvre to prevent (or abort) symptoms. Physiologically, this approach can be thought of as a haemodynamic equivalent, in the upright position, of raising the legs of recumbent patients to treat hypotension or shock. Although the effect of raising the legs is not immediate and is ascribed to increasing venous return,4 it is likely that raising the arms, which contribute little venous return, instantly increases cerebral arterial pressure as a result of the higher column of blood in the arteries of the raised arms. Cerebral perfusion is enhanced at the expense of the arms in which the arteries are gradually drained (radial systolic surge is felt). Raising the arms provides a sort of endogenous counterpulsation, bridging the interval until cardiovascular compensating adjustments become effective. So, raise your arms if you are fainting. *Bruno Simini, Yvonne Fritz-Simini Via del Campaccio 230, Gattaiola, 55050 Lucca, Italy
1 2
3
4
Editorial.The giraffe’s parameter. Lancet 1974; ii: 1491. Adams RD, Martin JB. Faintness, syncope and seizures. In: Petersdorf RG, Adams RD, Braunwald E, Isselbacher KJ, Martin JB, Wilson JD, eds. Harrison’s principles of internal medicine. New York: McGraw-Hill, 1983: 76–82. Tanaka H,Yamaguchi H,Tamai H.Treatment of orthostatic intolerance with inflatable abdominal band. Lancet 1997; 349: 175. Sobel BE, Roberts R. Hypotension and syncope. In: Braunwald E, ed. Heart disease. Philadelphia: Saunders, 1988: 884–95.
DEPARTMENT OF ERROR Randomised placebo-controlled trial of abciximab before and during coronary intervention in refractory unstable angina: the CAPTURE study—Two errors occurred in this article by the CAPTURE investigators (May 17, p 1429). In figure 1, the middle box of the righthand column of the figure should have read 622 received abciximab, 8 did not receive abciximab. In table 3, the percentage of all major bleeding in the placebo group is 1·9% (12 events). Diagnosis of appendicitis—In this correspondence letter by A J Malone and M R Shetty (June 14, p 1774), the last sentence of the fourth paragraph should read: “The CT examination is not operator dependent as is, for example, ultrasound. However, it is interpreter dependent and the radiologist . . .”.
Vol 350 • September 6, 1997
5
Maley W.The dynamics of regime transition in Afghanistan. Central Asian Survey 1997; 16: 167–84. Maley W.Women and public policy in Afghanistan: a comment. World Devel 1996; 24: 203–06.
Decline in mortality from testicular cancer in West Germany after reunification
Standard mortality rate (per 100 000 people)
SIR—Testicular cancer is one of the most curable adult solid tumours with the demonstrated efficacy of treatment in clinical trials1 brought to bear on entire populations in which the gap between increasing incidence and decreasing mortality is gradually widening.2 P Boyle and colleagues3 pointed out that the dramatic decline in mortality from testicular cancer seen in many developed countries was not present in central and eastern Europe because of the lack of financial resources to purchase the expensive drugs necessary to treat disseminated testicular cancer. The economic situation in the countries of central and eastern Europe has undergone radical change together with major changes in health care.4 For example, economic improvement and the establishment of a central treatment centre has been successful in reducing mortality from testicular cancer in Slovakia.5 Since 1980, mortality data from the former German Democratic Republic (GDR) has been available. Of all the former territories of central and eastern Europe, arguably the most sudden and notable change took place here. In the former Federal Republic of Germany (FRG), the mortality rate of testicular cancer peaked in the mid 1970s; by 1995, the mortality rate (0·4 per 100 000 people) was less than onethird of that in 1977 (1·4 per 100 000 people). By contrast, in the former GDR, the mortality rate did not change until the opening of the border in 1989 (1·5 per 100 000 people) and has substantially declined by 50% (figure). The current mortality rate (0·7 per 100 000 people) is slightly higher in the territories of former GDR than that in former FRG (0·4 per 100 000 people). The decline in mortality from testicular cancer in the former GDR has 2·0 1·8 1·6 1·4 1·2 1·0 0·8 0·6 0·4 0·2 0
West Germany East Germany 95 19 0 9 19 5 8 19 0 8 19 5 7 19 0 7 19 5 6 19 0 6 19 5 5 19 0 5 19
Year Secular trend of mortality for malignant neoplasm of testis (ICD 186)
744
paralleled the economic changes after German reunification and lends support to the hypothesis that economic factors had previously limited the implementation of new treatment for this curable cancer. *Nikolaus Becker, Peter Boyle *Division of Epidemiology, Cancer Prevention Unit, Deutsches Krebsforschungszentrum, D 69120 Heidelberg, Germany; and Division of Epidemiology and Biostatistics, European Institute of Oncology, Milan, Italy
1
2
3
4
5
Einhorn LH, Donohue JP. Cisdiamminedichloroplatinum, vinblastine and bleomycin combination chemotherapy in disseminated testicular cancer. Ann Intern Med 1977; 87: 293–99. Boyle P, Kaye SB, Robertson AG. Changes in testicular cancer in Scotland. Eur J Cancer Clin Oncol 1987; 23: 827–30. Boyle P, Maissonneuve P, Kaye SB.Testicular cancer in Central Europe. Lancet 1990; 335: 1033, Zatonski WA, Boyle P. Health transformations in Poland after 1988. J Epidemiol Biostat 1996; 1: 183–97. Plesko I, Ondrus D, Boyle P. Evolution of testicular cancer incidence and mortality in Slovakia, 1968–1990. Lancet 1996; 347: 900–01.
Raise your hands if you are fainting SIR—Giraffes do not raise their heads abruptly, they would faint if they did. A column of blood in their neck exerts a pressure of about 120 mm Hg and central arterial pressure cannot instantly increase by this amount as it should to prevent cerebral perfusion from dropping.1 This type of postural hypotension (a fact lions must be aware of) is normal among giraffes. Imagine now that they had a trunk like the elephant. Could they avoid fainting by thrusting their proboscis in the air before quickly raising their head? Human beings with orthostatic hypotension, it seems, can do so with their arms. Measures recommended for postural hypotension include: compression of veins in the lower extremities (exercising leg muscles, wearing tight stockings); expansion of extracellular volume (highsalt diet, salt-retaining steroids); treatment with sympathomimetic amines (eg, ephedrine);2 and abdominal compression.3 Might raising the arms, a simple manoeuvre hitherto not reported, be added to them, as the following case report suggests? An otherwise healthy man aged 42 years who was taking no drugs and had a history of mild postural hypotension (occasional transient dizziness and nearsyncope on arising from sitting, squatting, or recumbency) was told to lie in a hot bath for 15 min and, to precipitate symptoms, to stand up rapidly, either with his arms raised, keeping them up for 15 s or after repeated exercising of his leg muscles
(20 foot flexions and extensions and standing on and off his toes once upright). He stood up six times with intervals of 5 min on each of three days. Dizziness or near-fainting was invariably reported instantly or within seconds of standing up after exercising his legs, but did not occur when his arms were raised. In the latter posture he always reported a distinct awareness of his radial pulses. His heart rate increased slightly in both positions. Since then, in situations that cause him postural hypotension, he successfully uses this manoeuvre to prevent (or abort) symptoms. Physiologically, this approach can be thought of as a haemodynamic equivalent, in the upright position, of raising the legs of recumbent patients to treat hypotension or shock. Although the effect of raising the legs is not immediate and is ascribed to increasing venous return,4 it is likely that raising the arms, which contribute little venous return, instantly increases cerebral arterial pressure as a result of the higher column of blood in the arteries of the raised arms. Cerebral perfusion is enhanced at the expense of the arms in which the arteries are gradually drained (radial systolic surge is felt). Raising the arms provides a sort of endogenous counterpulsation, bridging the interval until cardiovascular compensating adjustments become effective. So, raise your arms if you are fainting. *Bruno Simini, Yvonne Fritz-Simini Via del Campaccio 230, Gattaiola, 55050 Lucca, Italy
1 2
3
4
Editorial.The giraffe’s parameter. Lancet 1974; ii: 1491. Adams RD, Martin JB. Faintness, syncope and seizures. In: Petersdorf RG, Adams RD, Braunwald E, Isselbacher KJ, Martin JB, Wilson JD, eds. Harrison’s principles of internal medicine. New York: McGraw-Hill, 1983: 76–82. Tanaka H,Yamaguchi H,Tamai H.Treatment of orthostatic intolerance with inflatable abdominal band. Lancet 1997; 349: 175. Sobel BE, Roberts R. Hypotension and syncope. In: Braunwald E, ed. Heart disease. Philadelphia: Saunders, 1988: 884–95.
DEPARTMENT OF ERROR Randomised placebo-controlled trial of abciximab before and during coronary intervention in refractory unstable angina: the CAPTURE study—Two errors occurred in this article by the CAPTURE investigators (May 17, p 1429). In figure 1, the middle box of the righthand column of the figure should have read 622 received abciximab, 8 did not receive abciximab. In table 3, the percentage of all major bleeding in the placebo group is 1·9% (12 events). Diagnosis of appendicitis—In this correspondence letter by A J Malone and M R Shetty (June 14, p 1774), the last sentence of the fourth paragraph should read: “The CT examination is not operator dependent as is, for example, ultrasound. However, it is interpreter dependent and the radiologist . . .”.
Vol 350 • September 6, 1997