Lawyer: "So, Doctor, you determined that a gunshot wound was the cause of death of the patient?"
Doctor: "That's correct.
Lawyer: "Did you examine the patient when he came to the emergency room?"
Doctor: "No, I performed the autopsy."
Lawyer: "OK, were you aware of his vital signs when he was at the hospital?"
Doctor: "He came into the emergency room in shock and died a short time later."
Lawyer: "Did you pronounce him dead at that time?"
Doctor: "No, I am the pathologist who performed the autopsy. I was not involved with the patient initially."
Lawyer: "Well, are you sure then, that he died in the emergency room."
Doctor: "That is what the records indicate."
Lawyer: "But if you weren't there, how could you have pronounced him dead, having not seen or physically examined the patient at that time?"
Doctor: "The autopsy showed massive hemorrhaging in the chest area and that was the cause of death."
Lawyer: "I understand that, but you were not actually present to examine the patient and pronounce him dead, isn't that right?"
Doctor: "No, sir, I did not see the patient or actually pronounce him dead, but I did perform the autopsy and right now his brain is in a jar over at the county morgue. As for the rest of the patient, for all I know, HE COULD BE OUT PRACTICING LAW SOMEWHERE!!"

Herpes labialis, a common problem, typically causes prodromal symptoms of tingling and burning followed by a painful lip lesion that lasts for 5-7 days. Topical and systemic treatments that have been promulgated have not been entirely effective. This randomized double-blind placebo controlled trial used 701 immunocompetent adults who had had at least three episodes of herpes labialis in the preceding year. Participants also had to have had prodromal symptoms and had their lesions progress to vesicles. Patients were randomized to receive placebo or famciclovir (Famvir) as a single 1500-mg dose or as two 750-mg doses on the same day. Both of the famciclovir regimens reduced the time to healing by two days. Neither regimen though completely aborted the attacks. Adverse effects were similar in both groups. For patients with this common recurrent disease this self-directed treatment begun within an hour of prodromal symptoms seems safe and effective. (J Am Acad Dermatol 2006 Jul; 55:47-53)

Invasive breast cancer will strike more than 200,000 women this year in the United States. Prevention has emphasized life style modification, i.e. diet, alcohol intake, optimizing weight and exposure to estrogens as well as ablative surgery for those at highest risk. More recently studies have looked at chemo prevention using selective estrogen receptor modulators such as tamoxifen and raloxifene. The recent STAR trial (Study of Tamoxifen and Raloxifene) compared 20mg of tamoxifen with 60mg of raloxifene over five years, in almost 20,000 post-menopausal women. Three hundred thirty one cases of invasive breast cancer were diagnosed during the follow-up period of four years, roughly equally split between the tamoxifen and raloxifene groups. Raloxifene was associated with slightly fewer thromboembolic events and fewer hysterectomies and cataracts where as tamoxifen was associated with a trend toward fewer cases of non-invasive breast cancer. (JAMA 2006 June 21; 295:2727-41) (JAMA 2006 June 21; 295:2742-51) (JAMA 2006 June 21; 295:2784-6)

Another recent study looked at raloxifene as a preventive measure in women with above average coronary risk. More than 10,000 post-menopausal women were randomized to receive daily raloxifene, 60-mg or a placebo. During follow-up for 5.5 years, there was no significant difference between raloxifene and the placebo groups in the incidence of coronary death and non-fatal coronary infarction. However, there was a lower incidence of invasive breast cancer with raloxifene, lower incidence of vertebral fractures but a higher incidence of fatal strokes and a higher incidence of venous thromboembolic disease. Whether these studies will allow primary care physicians to make definitive decisions about offering chemo prevention for breast cancer to their individual patients remains to be seen. (N Engl J Med 2006 Jul 13; 355: 190-2)

John J. Mohr, M.D.