SUMMARY Background : Non‐cardiac chest pain is a common condition affecting approximately one‐quarter of the population during their lifetime, but the long‐term economic costs of non‐cardiac chest pain are poorly defined. Methods : A MEDLINE and Current Contents search was performed from 1991 to 2002 using specific keywords. All major articles on the subject of non‐cardiac chest pain in this period were reviewed and their reference lists searched. Results : Limited studies suggest that the majority of those with non‐cardiac chest pain do not consult a doctor regarding their symptoms; the drivers of health care seeking are not known. The impact on the quality of life in consulters can be severe, with as many as 36% reporting much lower quality of life levels. The diagnosis of non‐cardiac chest pain can be difficult due to the heterogeneous nature of the condition, with significant overlap of gastro‐oesophageal reflux disease, chest wall syndromes and psychiatric disease, which may drive up the costs of management. The prognosis appears to be good, but there are conflicting results in long‐term studies. Conclusions : The costs of non‐cardiac chest pain to the health care system are likely to be large and represent a significant proportion of each Western country's health care budget. Further studies are required to determine methods of reducing health care costs.

The increasing human lifespan and development of technology over the last number of decades has seen an increase in the number of pacemaker and implantable cardioverter defibrillator (ICD) implantations worldwide. Given the number of risk factors common to both heart disease and cancer, it is not uncommon for several of these patients to present for radiation therapy treatment each year. A systematic review was conducted using online databases Medline and Scopus. Results were grouped into in vitro and in vivo studies. In 1994, the American Association of Physicists in Medicine (AAPM) defined guidelines for the management of these patients, which have since been adopted by many radiation oncology departments internationally. More recently, a number of studies have reported an increase in radiation sensitivity of these devices (encompassing the coiled metal leads and generator unit) due to the incorporation of complementary metal oxide semiconductor circuitry. Further avenues of device failure, such as the effect of dose rate and scatter radiation, have only more recently been investigated. There are also the unexplored avenues of electromagnetic interference on devices when incorporating newer treatment technologies such as respiratory gating and intensity modulated radiation therapy. It is suggested that each radiation oncology department employ a policy for the management of patients with ICDs and pacemakers, potentially based upon an updated national or international standard similar to that released by the AAPM in 1994.

Chest pain is common: one in four of the population have an episode annually. Of those who present to hospital, nearly two-thirds have noncardiac chest pain. More than half of these cases might have gastroesophageal reflux disease. Opinion differs over what is the most appropriate application of current investigatory methods. Evidence suggests that, once cardiac disease is ruled unlikely, empiric use of a proton pump inhibitor is an option; if acid suppression fails, detailed investigations as clinically indicated can be considered. A range of esophageal investigations is available, including 24-hour or 48-hour esophageal pH testing and esophageal manometry, as well as provocative tests, but there is no consensus as to which methods are the most useful. Psychiatric evaluation is not routine, but psychiatric or psychological disorders are common. Musculoskeletal disorders are also common, but are frequently overlooked. It is possible to subject patients to a comprehensive set of investigations before empiric therapy, but recent studies have failed to demonstrate an improved outcome using this exhaustive approach. A new tactic is required, with less attention spent on absolute diagnostic accuracy and more emphasis on optimizing the long-term clinical outcome in patients with noncardiac chest pain. It is possible that the targeted use of multiple drug trials in a policy of 'therapy as investigation' might be a superior methodology.

Background and aims: There is a clear need for a new approach to the treatment of obesity, which is inexpensive and is effective for establishing lifestyle change. We conducted a pilot study to evaluate whether dexamphetamine can be used safely, combined with diet and exercise, for treating obesity. Our ultimate aim is to develop a 6-month treatment program for establishing the lifestyle changes necessary for weight control, utilizing dexamphetamine for its psychotropic effect on motivation. We viewed the anorexigenic effect as an additional advantage for promoting initial weight loss.Methods: Obese adults were treated with dexamphetamine for 6 months (maximum of 30 mg twice daily), diet, and exercise. Weight, electrocardiogram, echocardiogram, and blood pressure were monitored.Results: Twelve out of 14 completed 6 months treatment. Weight loss by intention to treat was 10.6 kg (95% CI 5.8–15.5, p < 0.001). The mean weight gain in the 6 months after ceasing dexamphetamine was 4.5 kg (95% CI 1.9–7.2, p = 0.003), leaving a mean weight loss at 12 months from baseline of 7.0 kg (95% CI −13.4 to −0.6, p = 0.03). All reported favorable increases in energy and alertness. Dose-limiting symptoms were mood changes (2) and insomnia (2). None had drug craving on ceasing dexamphetamine, and there were no cardiac complications. Among the seven women, there was a significant correlation for those who lost most weight on treatment to have the least regain in the following 6 months (r = 0.88, p = 0.009).Conclusion: Our treatment with dexamphetamine, diet, and exercise was well tolerated and effective for initial weight loss. Future research will focus on identifying baseline predictive variables associated with long-term weight control.