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Surgery for Emphysema
This article reports the partial results of a cooperative study sponsored by Medicare and the National Institutes of Health in which medical and surgical management of emphysema were compared. The investigators found that among patients with a severe reduction in lung function, surgery resulted in more deaths during the first 30 days than did medical management and that the condition of patients who survived the surgery was not substantially improved.
These data represent the first controlled analysis of surgery for emphysema and indicate that there is a group of patients with severe disease for whom surgical management is unlikely to be of value.
Related Editorial
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Prognosis after Transient Monocular Blindness Associated with Carotid-Artery Stenosis
Two types of transient ischemic attacks may occur in patients with internal-carotid-artery stenosis — transient monocular blindness and hemispheric transient ischemic attacks. In this large study, the risk of subsequent ipsilateral ischemic stroke was about half as great among patients with transient blindness as among those with hemispheric ischemic attacks.
This study provides valuable prognostic information regarding patients with the common symptom of transient monocular blindness. A second analysis, which was not definitive, left open the possibility that carotid endarterectomy may reduce the risk of subsequent stroke in patients with transient monocular blindness and other risk factors for stroke.
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Adjuvant Chemotherapy for Resected Colon Cancer in Elderly Patients
After successful surgery for colorectal cancer, patients over 70 years of age are less likely to receive postoperative (adjuvant) chemotherapy than younger patients, even though it prolongs life. The underuse of chemotherapy relates to the belief that it is excessively toxic in the elderly. This analysis of data from seven randomized trials of adjuvant chemotherapy for resected colorectal cancer found that selected older patients not only benefit from such treatment but tolerate it almost as well as their younger counterparts.
The authors make a persuasive case for adjuvant chemotherapy in otherwise healthy elderly patients with resected colorectal cancer. Careful evaluation is necessary before such treatment is chosen, but there is no reason to withhold adjuvant chemotherapy routinely from older patients.
Related Editorial
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Infliximab and Tuberculosis
Infliximab, a humanized antibody against tumor necrosis factor  (TNF-), is used to treat rheumatoid arthritis and Crohn's disease. The Food and Drug Administration has received reports of 70 patients in whom active tuberculosis developed after treatment with infliximab for a median of 12 weeks. There were at least four deaths from tuberculosis.
Physicians should screen patients for tuberculosis before initiating treatment with infliximab. Among patients with rheumatoid arthritis, the rate of tuberculosis associated with infliximab therapy appears to be four times the expected rate. The association of active disease with anti–TNF- therapy suggests that TNF- may have a role in the control of latent tuberculosis infection.
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Special Article: The Effects of Lack of Health Insurance on Health in Late Middle Age
Approximately one in six people in the United States between 55 and 65 years of age lacks health insurance. This prospective study examined the independent effects of the lack of insurance on the health of a national sample of adults who were between 51 and 61 years old in 1992. The study found that people who were continuously uninsured or intermittently uninsured between 1992 and 1996 were more likely to have a major decline in overall health than those who continuously had health insurance. They were also more likely to have a new difficulty in walking or climbing stairs.
This study adds to the evidence that the lack of health insurance is associated with an increased risk of a decline in overall health. It underscores the importance of increasing health insurance coverage among adults in late middle age.
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Clinical Practice: Extracranial Carotid Stenosis
A 64-year-old man with a history of smoking and hypercholesterolemia has a sudden, transient loss of vision in his left eye. The results of the physical examination are normal except for a bruit in the left side of the neck. High-resolution carotid ultrasonography demonstrates stenosis of 60 to 79 percent in the left carotid artery that is confirmed by magnetic resonance angiography. How should this patient be treated?
This article reviews the treatment of patients with symptomatic or asymptomatic carotid stenosis.
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