Screening for microalbuminuria predicts those patients most likely to develop progressive renal failure. Early treatment with an angiotensin converting enzyme inhibitor reduces the rate of deterioration in renal function in patients with diabetic nephropathy. Two recent studies have favoured screening with early treatment, but neither study examined the impact of false labelling and treating diabetic patients with angiotensin converting enzyme inhibitors, a reduction in the cumulative incidence of diabetic nephropathy, or the numbers that would be already detected by hypertension at the onset of microalbuminuria. On p 1595 Kiberd and Jindal show that these variables could make screening costly. Their study examined what must be known and how physicians must practise if screening for microalbuminuria is to be cost effective compared with a strategy of treatment with angiotensin converting enzyme inhibitor in patients with hypertension or macroproteinuria, or both.
Knowledge of the natural history of sickle cell disease has been heavily based on the symptoms found in patients in hospitals and clinics. The Jamaican cohort study provides a representative sample of patients and includes all cases detected among 100,000 consecutive babies delivered non-operatively. On p 1600 Lee et al report the group's follow up from birth, with documentation of cause and age at death. Simple interventions have been developed to address the common causes of death, especially pneumococcal septicaemia and acute splenic sequestration. The impact of follow up and other interventions - including pneumococcal prophylaxis and educating parents about the early signs of acute splenic sequestration - was assessed by examining survival in the first, second, and last thirds of the group. There was a significant improvement in survival attributable principally to the two specific interventions. Simple measures, implementable in most countries with limited resources, may improve survival in homozygous sickle cell disease. This is a more realistic approach to a major population problem than manipulating fetal haemoglobin concentrations with hydroxyurea or than high technology approaches such as bone marrow transplantation.
It has been suggested that selegiline hydrochloride might have beneficial effects on the natural course of Parkinson's disease and improve patients' life expectancy. The Parkinson's Disease Research Group of the United Kingdom is conducting a continuing trial of different treatments for mild Parkinson's disease; on p 1602 A J Lees, on behalf of the group, presents the results of an interim analysis of the therapeutic effects of levodopa alone and levodopa combined with selegiline. After an average of 5.6 years of follow up mortality was about 60% higher in the patients given combined treatment than in those given levodopa alone, and this effect was independent of sex and age. Disability scores were slightly, non-significantly higher in the patients given levodopa alone, but severe motor complications were more frequent with combined treatment. The group concludes that levodopa in combination with selegiline seemed to confer no clinical benefit over levodopa alone while the significantly higher mortality found with combination treatment casts doubt on its long term use in Parkinson's disease.
A case has been made to measure cholesterol concentration in routine health checks because "knowing your cholesterol number" motivates people to modify their behaviour. In a randomised controlled trial Hanlon et al (p 1609) compared changes in risk factors for coronary heart disease and health related behaviours resulting from various types of feedback that had been given to six separate groups in two Glasgow work sites. Feedback on cholesterol concentrations or on coronary risk score did not in itself motivate subjects to change their behaviour. A full health check did, however, result in quite large changes in some self reported behaviours (alcohol consumption and diet), although there was no substantial effect on reversible coronary risk. The authors conclude that cholesterol concentration should not be used to motivate behaviour change and that health checks should be used, if at all, to promote changes in health related behaviour.