During three to six months of lactation a woman's bone
mineral density falls by 3-5% in the lumbar spine and femoral neck and
1-2% in the whole body, but the loss is transient. Giving calcium
supplements during lactation has little or no effect (New
England Journal of Medicine 1997;337:523-8, 558-9), and it
seems that the temporary mobilisation and later restitution of the bone
mineral are independent of the dietary intake of calcium.
Presented with a patient with a troublesome knee, a surgeon has
to choose between ordering a magnetic resonance imaging scan or
proceeding directly to arthroscopy. A review in the Journal of
Bone and Joint Surgery (1997;79B:520) concludes that magnetic
resonance imaging is a reliable alternative to diagnostic arthroscopy
and is cheaper: so if a surgically treatable lesion seems unlikely then
the scan should be the first choice.
One of the most frequent questions asked by patients told they
have cancer is how long they may expect to live. A type of computer
program called an artificial neural network has been shown to give
better estimates of life expectancy for patients with colorectal cancer
than those given by their surgeons (Lancet
1997;350:469-72). The networks were supplied with data on 42
variables collected over five years from 334 patients. The overall
accuracy of the computer predictions of death within 12 months was 90%
as against 79% and 75% by two surgeons.
Patients with haematological disorders such as idiopathic
thrombocytopenic purpura will often benefit from having their spleens
removed. This operation can be performed laparoscopically, and 265
cases have been reported, mostly in small series (The American
Surgeon 1997;63:700-3). Patients having the laparoscopic
operation spend an average of 1.5 days in hospital and have less
postoperative discomfort.
The aetiology of oesophageal reflux disease remains contentious,
but a review in the American Journal of Gastroenterology
(1997;92:1097-102) concludes that "the case for an important
association between Helicobacter pylori and
gastro-oesophageal reflux is weak, some might even suggest
ridiculous." Nevertheless, says the review, the possibility warrants
further investigation.
A prospective study of 855 men born in Gothenburg in 1913 found
that by the age of 80 the cumulative probability of a thromboembolic
event was 10.7% (Archives of Internal Medicine
1997;157:1665-70). Major pulmonary embolisms were found in
4.8% of all the men who died during the study, a similar proportion to
that found in the Framingham study during 26 years of follow up. The
rate in men seems to be higher than that in women.
Intravenous immunoglobulin is an expensive treatment for the
chronic fatigue syndrome that has been claimed to improve patients'
physical and mental health. A randomised placebo controlled trial in 99
patients compared intravenous immunoglobulin injections with albumin
injections (American Journal of Medicine 1997;103:38-43)
and found that both groups of patients reported benefits, but there was
no difference in the outcome measures. Side effects were common. The
authors concluded that the treatment cannot be justified on the
evidence currently available.
The problem with evidence based medicine is that so little of
the evidence is solid enough to stand up to rigorous examination. Two
articles in the British Journal of Psychiatry
(1997;171:113-9, 120-40) reach opposite conclusions about the evidence
for the use of lithium in the treatment of acute mania, the prophylaxis
of bipolar disorder, and the augmentation of treatment in resistant
depression. Readers are left with the unsatisfactory conclusion that
more research is needed - despite the vast number of papers already
published on this topic.
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.
Volatile nitrites are apparently popular street drugs, but
people who swallow "poppers" rather than inhaling them may develop
severe methaemoglobinaemia (Journal of Accident and Emergency
Medicine 1997;14:339-40). Only if the condition is recognised
will the appropriate treatment be given with intravenous methylene
blue.
Two articles in the Canadian Medical Association Journal
(1997;157:281-5, 291-3) spell out the deterioration in public
health in Cuba as a result of the tightening by the United States of
its trade embargo on medicines and food. One casualty has been the
mammography programme, which has been shut down because of equipment
failure and lack of film and developer.
Gastroenteritis due to Escherichia coli O157-H7
is usually associated with undercooked minced beef, but a report in
Epidemiology and Infection (1997;119:1-8) describes an
outbreak affecting campers in New York State who swam in a lake.
Several other reports have linked the organism with swimming in fresh
water.
The incidence of breast cancer has doubled in Singapore in the
past 25 years (Cancer 1997;80:725-31). A case-control
study in 1086 women found strong evidence of an increased risk in women
who were obese, particularly those with central obesity. Tall women had
twice the risk of short ones. Other factors included change in family
size and the timing of births.
Patients who have been diagnosed as having the irritable bowel
syndrome spend more of their sleep in the rapid eye movement phase than
do controls (Gut 1997;41:390-3). The research group in
Oklahoma who reported this finding believe that it suggests an
intrinsic alteration in autonomic and central nervous system
functioning in patients with the syndrome.
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