One factor in the increase in the numbers of patients with
multidrug resistant tuberculosis is the poor quality of treatment - and
its supervision - in the private sectors of countries of all levels of
prosperity. An editorial in Chest (1997;111:1149-51)
argues that the most effective solution is to persuade the
manufacturers to remove from the market all single formulations of
rifampicin, isoniazid, pyrazinamide, and ethambutol. Only combination
products should be available for use.
Children with chronic renal insufficiency grow more slowly than
normal, but this growth failure is now treatable. Long term studies
have shown (Nephron 1997;76:125-9) that treatment with
recombinant human growth hormone closes the gap in height and continues
to do so while the treatment continues. Children treated for five years
have shown no adverse effects.
Autologous blood transfusion ought to be entirely safe, but it has become so popular that the scale of the collection and distribution process makes errors inevitable. A study in Canada of 70,000 units collected (Transfusion 1997;37;523-7) showed that something went wrong in 279 cases: mostly late delivery of the blood to the operating theatre, blood sent to the wrong hospital, and so on. In one case a unit was transfused into the wrong recipient. Errors were most common when the blood was processed into components.
Treatment for carcinoma of the larynx causes functional,
cosmetic, and psychological disability. Most patients say they would
like a laryngeal transplant if that was possible. An editorial in the
British Journal of Surgery (1997;84:739-40) reviews the
revival of interest in transplantation, which is making progress in
experiments on pigs. There is no immediate prospect of surgery on
patients.
A small outbreak of rubella among British troops serving in
Bosnia caused some alarm because of the 620 women among the personnel
(Epidemiology and Infection 1997;118:253-7). One woman
soldier who was pregnant was flown out of Bosnia as a precaution.
Policymakers are now trying to decide whether all recruits to the armed
forces should be immunised with measles-mumps-rubella vaccine whatever
their vaccination status.
The Romans and the ancient Egyptians had names for wines
suggesting that they believed that they induced abortion, but research
publications give conflicting opinions on the effects of moderate
drinking on the risk of miscarriage (Alcohol and
Alcoholism 1997;32:211-9). Studies in the United States have
mostly found an effect, while those in Europe and Australia have not.
Confounders such as smoking make the topic more difficult; yet again
the conclusion is that the published work is unsatisfactory and more,
better research is needed.
Taking the contraceptive pill puts up the basal metabolic rate
(British Journal of Nutrition 1997;77:827-31). A study
of 24 women and 22 controls found that the women on the pill had
metabolic rates 5% higher than the controls and slightly higher blood
pressures; the differences persisted after the exclusion of women who
took a lot of exercise.
The list of indications for treatment with botulinum toxin
continues to lengthen. A double blind placebo controlled randomised
trial of injections of the toxin in 14 children with hemiplegia from
cerebral palsy appears in Developmental Medicine and Child
Neurology (1997;39:185-93). Most patients showed a reduction in
muscle tone, but the effects on function varied. The conclusion was
that the treatment seems likely to be useful in selected patients.
A case report in the Journal of the Royal College of
Surgeons of Edinburgh (1997;42:202-3) is a reminder that
infection with Strongyloides stercoralis is one
possibility in patients with persistent bloody diarrhoea: the patient
described had been treated for ulcerative colitis for 14 years before
the correct diagnosis was made.
The processes of Darwinian evolution may operate within a
malignant tumour over a period of years, so that in time the tumour
becomes more aggressive and invasive - as well as more resistant to
treatment. A review in Cancer (1997;79:2275-81) makes
these points and concludes that the earlier treatment can be started
the softer the target for the oncologist - further reason for early
diagnosis to be given high priority.
In developing countries hundreds of millions of farm workers and
their families are exposed to pesticide chemicals that have been banned
in the United States and Europe. A review in Health Policy and
Planning (1997;12:97-106) says that many of these chemicals
have been shown to have immunosuppressive actions in animals and may be
expected to interfere with the immune systems of men and women who come
into contact with them. Few developing countries have safety
legislation to protect farm workers, and even fewer enforce such laws.
The big clinical trials of high dose chemotherapy and autologous
bone marrow transplantation for metastatic breast cancer have not yet
reported, but in the United States metastatic breast cancer is now the
most common indication for autotransplantation. A review in
JAMA (1997;277:1827-9) says it is too soon to know
whether this treatment offers any real prospect of a cure, but
conventional treatment for metastatic disease has so little to offer
that women are choosing the option that gives them some
hope.
The standard treatment for a fracture of the scaphoid is still
immobilisation - which may need to be continued for 12 weeks or
sometimes longer. Screw fixation was first tried more than 40 years
ago; the technique has now been refined (Journal of Bone and
Joint Surgery 1997;77[Br]:418-21), and a minimally invasive
percutaneous method is used, with a guidewire and an image intensifier.
With this approach manual workers can be back at work in six
weeks.
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