AIDS in haemophilia is not due to high clotting factor usage
It has been suggested that clotting factor usage rather than HIV is the underlying cause of AIDS in men with haemophilia. On p 207 Sabin et al compare the development of new AIDS defining conditions and the CD4 cell counts of 17 HIV positive and 17 HIV negative patients matched for their usage of concentrate. AIDS events and deaths occurred only among HIV positive patients. Mean CD4 counts were substantially lower in HIV positive patients than in HIV negative patients. Sabin et al conclude that the hypothesis that high usage of clotting factor concentrate rather than HIV infection is the cause of immunodeficiency and AIDS in men with haemophilia is rejected by these data.
Early thrombolytic treatment for suspected acute myocardial infarction substantially improves long term survival
It is generally accepted that the earlier thrombolytic treatment is given for acute myocardial infarction, the greater the benefit. However, studies comparing treatment in the community with later treatment in hospital showed that earlier treatment did not significantly reduce mortality in the following month. On p 212 J Rawles presents new evidence from the Grampian region early anistreplase trial (GREAT) to show that earlier treatment in the community substantially improved long term survival. The results also provide an explanation for the apparently small benefit from earlier treatment previously reported: patients who sought medical help quickly after start of symptoms had more severe infarction, and thus a higher mortality risk, than those seeking help later. Without an appropriate trial design, this tendency can mask the greater efficacy of earlier thrombolysis. The author concludes that giving thrombolysis at the first opportunity is of the utmost clinical importance.
Adult mortality is a serious problem in sub-Saharan Africa
The problem of infant and child mortality in sub-Saharan Africa is widely known. In contrast, little is known about adult mortality. In Tanzania a study covering about 1% of the Tanzanian mainland population has been established to measure rates and causes of death in adults in one urban and two rural areas. On p 216 Kitange et al report the age and sex specific mortalities and the probability of death between the ages of 15 and 59, based on deaths reported during the first three years of monitoring. Their findings present a bleak picture with mortalities, for example, in 20 to 24 year old women in one rural area being over 40 times higher than in women of the same age in England and Wales. The authors suggest that while attention must continue to focus on child mortality there is now an additional need to turn the policy spotlight on the health of adults on whom the wellbeing of young and old depends.
Women at low risk often require intervention during delivery
The contribution of rural general practitioners to provision of acute care in rural areas is often overlooked. In a series of 997 consecutive deliveries booked at a rural general practitioner unit in southwestern Scotland, Baird et a/ (p 223) found that general practitioners managed many complications, but even so over half of all deliveries took place in a consultant led unit 120 km away. Complications and transfers at the rural unit required the support of medical practitioners in 30% of deliveries. One in six (85/462) had complications during delivery requiring emergency medical support, mainly resuscitation of babies with low Apgar scores, simple forceps deliveries, and control of postpartum haemorrhage. The study questions the assertion that most women can be considered at low risk during labour and emphasises the importance of general practitioners and midwives being prepared for medical intervention, mainly for postpartum haemorrhage and neonatal resuscitation.