The Expert Committee on the Diagnosis and Classification of
Diabetes Mellitus has recommended changes in the
diagnostic criteria for the various forms of the disease
(Diabetes Care 1997;20:1183-97). A casual plasma glucose
concentration of 11.1 mmol/l in a patient with symptoms will now be
enough. The terms "insulin dependent" and "non-insulin
dependent" are no longer acceptable, says the report, which prefers
type I and type II diabetes for the conditions in which there are
respectively insulin deficiency and insulin resistance.
Symptoms of rectal pain, blood or mucoid discharge, tenesmus,
and constipation suggest a rectal fissure, but another possibility that
should be borne in mind is genital herpes (Journal of the Royal
College of Surgeons of Edinburgh 1997;42:272-82). Rectal
infection with herpes simplex virus may occur in sexually active women
but need not be related to rectal sex. Unless tests are done for
sexually transmitted diseases the diagnosis may be missed.
A study in Sweden of 300 women aged 30-65 found a strong
social gradient in serum lipid concentrations, with an unhealthy lipid
profile more common in blue collar workers (Journal of
Epidemiology and Community Health 1997;51:400-7). Part of the
variation in lipids was associated with lifestyle factors, but other
strong determinants included the "decision latitude" at work
(factors such as taking part in decisions, skills, and creativity) and
annual income.
Cord blood banks are being set up world wide as evidence
accumulates that blood from the umbilical cord is a good source of
haematopoietic stem cells and may be used as a substitute for bone
marrow transplantation. Some data from the Eurocord Transplant Group
(New England Journal of Medicine 1997;337:373-81) show
that among 65 patients who received cord blood from unrelated donors
the Kaplan-Meier estimate of survival at one year was 29%. Results are
expected to improve as more experience is gained on the selection of
donors.
Should the partners of women being treated for bacterial
vaginosis be treated at the same time? A randomised controlled trial in
Italy (Genitourinary Medicine 1997;73:267-70) looked at
69 couples in which the partner was treated with clindamycin cream or
capsules and 70 couples in which the partner was given a placebo. All
the women were treated with clindamycin cream. Overall, 131 of the
women were cured, with no difference between those whose partners were
treated and those whose were not.
Cigarette smoking is thought to increase the risk of someone
developing rheumatoid arthritis, and some recent research in the United
States has now found that smoking also seems to affect the progress of
the disease (Annals of the Rheumatic Diseases
1997;56:463-9). The number of pack years of cigarette smoking
was associated with a positive rheumatoid factor, radiographic
erosions, and nodules. The authors believe it unlikely that increased
smoking is an effect rather than a cause of more severe disease.
The most important step in the decision whether or not to give
thrombolytic treatment to a patient with a possible acute myocardial
infarction is interpretation of the electrocardiogram. A study in
Glasgow (Heart 1997;78:198-200) has now shown that a
consultant's opinion on the electrocardiographic tracing can be
obtained out of hours by faxing it to his home. In a series of 112
patients managed in this way the interpretation of the
electrocardiogram was changed by the consultant in 10 cases.
Cardiologists on call need fax machines, says Heart in
an editorial (1997;78:108).
Minerva was surprised by some cost calculations in an article
from the Netherlands in the Journal of Medical Genetics
(1997;34:741-5). The authors compared the costs of DNA
diagnosis for some handicapping disorders such as muscular dystrophy
and the fragile X syndrome with the estimated lifetime costs for the
medical resources needed for the care of infants born with these
diseases. Lifetime costs ranged from £0.5m to £2m - figures in line
with awards by law courts but nevertheless so high as to make the costs
of antenatal diagnosis trivial.
Way back in the 1940s a project began at Johns Hopkins
medical school in which students recorded information on their health,
including their sleep patterns. Follow up of 1053 of these students
(American Journal of Epidemiology 1997;146:105-14) has
shown that 101 developed clinical depression and 13 had committed
suicide. The relative risk of depression was 2.0 for the men who
reported insomnia as students when compared with those who reported
normal sleep.
And some more on suicide: a report in the British Journal
of Dermatology (1997;137:246-30) describes 16 patients
attending one skin clinic who killed themselves. Seven of the 16 had
severe acne with scarring, only two of whom had had the opportunity to
receive treatment with oral isotretinoin. The authors recommend that
clinics treating patients with chronic skin disease should have the
services of a liaison psychiatrist.
Readers of Philip Roth's American
Pastoral will have been made aware of the miserable side
effects of radical prostatectomy - impotence and incontinence - yet
between 1984 and 1990 the age adjusted rate of this operation for early
prostate cancer increased sixfold in the United States. This increase
was, says the Journal of the National Cancer Institute
(1997;89:1117-23), partly attributable to claims by surgeons that the
newer nerve sparing operations are less likely to interfere with sexual
potency: yet in a series reported in the journal more than two thirds
of the men having surgery reported complete impotence 12 months after
surgery.
The last month has been unusually hot in Britain, but it has
been even hotter in parts of the United States: temperatures of over
40|SDC have been recorded in Dallas (Morbidity and Mortality
Weekly Report 1997;46:528-31). Since 1979 around 6000 "heat
related" deaths have been recorded in the US, mostly in very young
babies and elderly people. Drugs that increase the risk of death in hot
weather include neuroleptics and any drugs with anticholinergic
actions.
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