The Oregon Health Plan, with its prioritised list of medical
treatments, came into operation in 1974 and has since proved
politically popular, says a report in the New England Journal of
Medicine (1997;337:651-5). The choices have proved acceptable
both to patients and to doctors, and 100 000 people have been added to
the Medicaid programme. If cuts have to be made in a medical service
they may be most acceptable if money is saved by excluding treatments
of unproved effectiveness.
Is hepatitis A sometimes transmitted sexually? An outbreak in
London reported in the Scandinavian Journal of Infectious
Diseases (1997;29:211-2) adds to the evidence that it may be.
The infection is more common in homosexual men than in the general
population. The link is not too surprising - oral-anal contact might be
expected to spread gastrointestinal pathogens.
Metformin, a biguanide drug used in the management of
non-insulin dependent diabetes, may cause lactic acidosis in patients
with impaired kidney function. The Royal College of Radiologists has
recently issued advice to its members and fellows reminding them of the
need to ask patients referred for contrast investigations whether they
are taking metformin. Anyone taking the drug should stop taking it for
48 hours before and 48 hours after any x ray contrast
medium examination.
Might giant cell arteritis be provoked by exposure of the skin
to sunlight? This suggestion was first made 20 years ago, but it has
been revived in a report from Australia ( Pathology
1997;29:260-2) of two patients with giant cell arteritis and
actinic granulomas. The report shows that giant cell arteritis varies
with the season, with its peak incidence in the summer months.
The internet's latest foray into medical controversy is an
appeal for volunteers for a trial of a live attenuated vaccine against
HIV. According to Science (1997;277:1035) the
organisation making the appeal is "the little known International
Association of Physicians in AIDS," which is hoping to recruit a few
hundred volunteers for a study of a vaccine similar to one that has had
striking success in experiments on monkeys. A live vaccine eliminated
smallpox and another is well on the way to eliminating poliomyelitis,
but a weakened HIV virus could change a lot over 30 years, says the
report. No trial can answer all the safety questions until the follow
up has extended to the end of the lives of the volunteers treated.
Fifty years have passed since the worst of the summer
epidemics of poliomyelitis in Europe and the United States, but nearly
two million survivors are still at risk of developing the "post-polio
syndrome." This takes the form of the unexpected onset of symptoms of
fatigue, weakness, pain, and cold intolerance, causing problems with
daily living ( Mayo Clinic Proceedings 1997;72:627-38).
Patients with these symptoms need individual assessment and then some
sort of team approach to management. Fortunately support groups for
people with the post-polio syndrome provide practical and psychological
help.
Research in Switzerland has shown that patients with persisting
symptoms after whiplash injuries to the neck have abnormalities in
brain glucose metabolism that can be detected by single photon emission
computed tomography and positron emission tomography. The report in the
Journal of Neurology, Neurosurgery, and Psychiatry
(1997;63:373-5) comments that, though these are expensive
techniques, they may provide objective data that could resolve
medicolegal controversies.
A case-control study of 328 men with cancer of the
prostate and 328 controls ( British Journal of Cancer
1997;76:678-87) found some reduction in risk for men who had eaten a
lot of baked beans, peas, and garlic (a somewhat implausible
combination). Pulses have been shown to have constituents that may
reduce the theoretical risk. Nevertheless, this remains one of the
major cancers for which the risk factors are largely unknown.
When presymptomatic testing for Huntington's disease became
possible many commentators forecast widespread distress among those
people who came forward to be tested. In fact, says Peter Harper in the
Journal of Medical Genetics (1997;34:749-52), over 1500
tests have been carried out in Britain and the experience here and in
other countries is that there have been few harmful effects. Most
people tested, regardless of the result, have felt benefited.
Central venous catheters are the leading cause of
nosocomial infection of the bloodstream, so any means of reducing the
risk would be welcome. A controlled trial in 281 patients of coating
the catheters with minocycline and rifampicin has given encouraging
results ( Annals of Internal Medicine 1997;127:267-74).
Twenty six per cent of the uncoated catheters became colonised as
against only 8% of the coated ones. Catheter related infections of the
bloodstream developed in seven patients with uncoated catheters but in
none of those whose catheters had been coated.
Current recommendations on children's diet aim to reduce their
intake of non-milk extrinsic sugars (table sugar; sugars and syrups
used in processing; honey; and sugars in fruit juices). The rationale
is the bad effect of these sugars on the teeth. A report in the
British Journal of Nutrition (1997;78:367-78) makes two
points: children who eat a lot of sugar eat less fat, and their high
sugar intake does not seem to lead to deficiencies of micronutrients
such as vitamins.
A survey in Avon of the parents of 12 103 babies aged 4 weeks
found that one quarter had had nappy rash ( British Journal of
General Practice 1997;47:493-9). Analysis of the responses
showed that a rash had occurred more commonly in babies who had been
ill, those who had had frequent bowel actions, and those who had been
started on cereals. Disposable nappies had little protective
effect.
Research workers in Oxford don't think much of the standard
tests for peripheral vascular disease: in a paper in the British
Journal of Surgery (1997;84:1107-9) they say that
"claudication distance is spuriously estimated, inaccurately
reported, falsely recorded, inappropriately measured, and usually
misinterpreted." Treatment should be based not so much on how far a
patient can walk as on whether he or she can walk as far as they want
to. This is the difference between disability and handicap.
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