It took two generations - not to mention some financial
incentives for general practitioners - before cervical screening became
accepted by most women in Britain. So what about screening for
colorectal cancer? An editorial in the Scottish Medical
Journal (1997;42:67) reports yet another study in which
compliance with sigmoidoscopy was below 30%. Should screeners just be
patient and wait for attitudes to change? Colorectal cancer kills many
more people than cancer of the cervix.
A study in Sweden of twin pairs aged 80 or older found that
monozygotic twins continued to show close similarities despite so many
years of exposure to the environment (Science
1997;276:1560-3). In these old people the heritability of
cognitive ability was 62% - a figure similar to that in adolescent
twins. So the balance between environmental and genetic influences on
intelligence shows little or no change with age.
The task of producing clinical guidelines must seem pretty
thankless to those who do the work. Recent guidelines for the
management of low back pain were evaluated in an audit of case notes of
963 patients (JAMA 1997;277:1782-6). The review showed
that 13% of the patients had had radiographs of their lumbar
spines - but, had the guidelines been followed, the proportion having
radiographs would have been 44%.
A supplement in Tropical Doctor (1997;suppl
1;1-67) reviews traditional remedies for malaria, vector control, wound
healing, and skin disorders. Minerva was interested in two reports of
plants that may contain effective molluscicides. In his introduction
Eldryd Parry warns that identifying the useful components of
traditional agents is difficult and that rigorous testing is
essential - comments that are, sadly, all too often ignored by
enthusiasts for anything "alternative."
A review of medical insurance claims made by employees of the
World Bank (Occupational and Environmental Medicine
1997;54:499-503) found that the rates were 80% higher for men
and 18% higher for women who travelled as part of their work. Claims
for psychological and infectious diseases were higher in frequent
travellers - as might have been expected - but so were claims for most
other categories of disease. Possible explanations suggested in the
report include exposure to sunlight, low humidity on aircraft, and
strains from carrying luggage.
In extracorporeal photochemotherapy a patient is given oral
methoxypsoralen, blood is removed and exposed to ultraviolet light, and
the blood is then returned. A leader in Annals of the Rheumatic
Diseases (1997;56:339-42) reports some small series of patients
with rheumatoid arthritis, systemic lupus erythematosus, systemic
sclerosis, and psoriatic arthritis treated by this technique; the
results were encouraging, but the conclusion is that this "apparently
unproved, relatively expensive, novel therapy" needs further
evaluation.
In surfer's ear, new bone is laid down in the ear canal,
sometimes reducing its lumen by 85-90% (The Remedy
1997;6(1):9-10). This reaction seems to occur in anyone who
spends enough time in the cold water found around the British Isles.
The ears feel blocked, but people with these lesions do not complain of
deafness, and surgical removal of the new bone is only rarely
necessary. Dedicated surfers should wear earplugs, which also protect
against otitis externa.
Attention deficit hyperactivity disorder/hyperkinetic disorder
is being diagnosed more often in children in Britain, though the rate
still lags far behind that reported in North America. A review in the
British Journal of Psychiatry (1997;170:489-91) says
that, although the received view is that the condition (or conditions)
usually resolve spontaneously, as many as 1% of young adults may be
affected. Unfortunately, controlled trials of the treatment of adults
with methylphenidate have given disappointing results.
Minerva was pleased to read in New Generation
(1997;June:7) an article for parents trying to come to terms with an
obstetric disaster, under the title "Someone to blame." This
emphasises the part played by anger in adjusting to loss and explains
that staff are now often so fearful of litigation that the simple
apology - "I'm really sorry" - is hardly ever heard. We should
somehow be able to find a way of letting doctors and midwives who feel
sorry to say so.
What should obstetricians be doing about the Barker hypothesis,
asks a commentary in the British Journal of Obstetrics and
Gynaecology (1997:104:645-7). If fetal undernutrition is an
important cause of ill health in adult life, should pregnant women be
given more dietary advice? Not if that means encouraging them to "eat
for two," says the article, pointing out that in Britain one third of
women in early pregnancy are already overweight, and half of those are
actually obese.
Transjugular intrahepatic portosystemic shunts (TIPS) provide an
alternative to endoscopic sclerotherapy in the prevention of recurrent
variceal haemorrhage in patients with portal hypertension. A randomised
controlled trial in Virginia (Annals of Internal
Medicine 1997;126:849-57) compared the treatments in 80
patients who had recovered from acute bleeding. In three years of
follow up no difference was seen in the rates of repeat bleeding, but
there were 12 deaths in the TIPS patients and only seven in those given
sclerotherapy.
Follow up of 12,058 children born in Finland in 1966 showed
that 503 boys and 53 girls had criminal records by the age of 26
(American Journal of Psychiatry 1997;154:840-5). Eleven
of the 165 violent offenders had been diagnosed as psychotic. The odds
ratio for a violent offence was 7.0 for people diagnosed as being
schizophrenic and 8.8 for those with mood disorders with psychotic
features.
Changes in the climate may have played a part in an upsurge of
cases of poisoning with the fungus Amanita phalloides in
California. Four more cases, two fatal, are reported in the
Morbidity and Mortality Weekly Report (1997;46:489-92).
The fungus may all too easily be mistaken for an edible mushroom,
especially now that it is growing in places where it has not grown
before. The only definitive treatment in cases of severe poisoning is
liver transplantation.
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