The incidence of coeliac disease in childhood has declined
in Britain in the past 20 years, but it has risen in Sweden and stayed
constant in Italy. A paper in Archives of Disease in Childhood
(1997;77:206-9) claims that these trends reflect changes in
infant feeding practices. The risk of an infant developing coeliac
disease is reduced if gluten is withheld until at least 5
months. Foods that are free of rice and gluten should be used for
initial weaning, the report concludes.
The current issue of Advances in Psychiatric
Treatment (1997;3:250-311) deals with the treatment and
management of sick doctors. It includes some helpful material on
dealing with stress and burnout, defined as "a progressive loss of
idealism, energy, purpose, and concern as a result of conditions at
work." The best protection against the harmful effects of stress may
be to ensure that the most enjoyable components of a job are not
sacrificed to meet clinical or administrative demands.
Despite directly observed therapy, enablers, and incentives,
some patients with tuberculosis remain persistently non-adherent - a
sentence in current jargon from a paper in JAMA
(1997;278:843-6) on a growing problem. New York City and California
have enacted measures that permit long term civil commitment of
patients who are persistently non-adherent. A study of 67 such patients
found - predictably enough - high rates of homelessness, alcohol misuse,
and mental illness.
Early operation is promoted as the way to reduce deaths from
rebleeding in patients who have had a subarachnoid haemorrhage, but a
study in the Netherlands of neurosurgical units committed to this
policy found that they actually managed to operate within three days in
only just over half the cases (Journal of Neurology,
Neurosurgery, and Psychiatry 1997;63:490-3). Rebleeding was the
main cause of a poor outcome, and the report calls for further studies
to investigate better ways of preventing it.
Clinicians continue to prescribe treatments for which
there is little or no evidence while failing to prescribe drugs from
which the benefits are unequivocal. For example, only one third of
Italian patients who have recovered from an acute myocardial infarction
get a ß blocker (European Heart Journal
1997;18:1447-56). Instead, many patients are given calcium
channel blockers, for which the evidence of benefit is scanty.
Herniography is a technique for detecting hernias in the
groin which are not obvious on clinical examination. Radiographic
screening is done after injection of 50 ml of contrast into the
peritoneal cavity. Experience in Leicester (Annals of the
Royal College of Surgeons of England 1997;79:372-5) found a
false positive rate of 19% and a false negative rate of 8%, and the
authors concluded that their experience was not as encouraging as
others had reported.
Data from an American prospective study of complications of
diabetes mellitus (Archives of Internal Medicine
1997;157:1851-6) have been used to calculate that for
microvascular complications to appear takes on average 83 years with a
glycated haemoglobin concentration 1% above the normal limit of
7.35%, 42 years at 2% above, 21 years at 4% above, and 18 years at
5% above normal.
Studies in the United States have found that between 30%
and 50% of people with psychotic illnesses also meet the criteria for
a diagnosis of primary substance misuse (British Journal of
Psychiatry 1997;171:205-8). In Europe, by contrast, there
has been far less recognition of the frequency of the dual diagnosis.
Alcohol, cannabis, and stimulants are the substances most frequently
misused. The rates of misuse may have increased as more patients
receive their care in the community.
Fat babies only rarely grow up to be fat adults, according to a
study in the United States: it found that only 8% of infants who were
obese were obese in early adult life (New England Journal of
Medicine 1997;337:869-73). By contrast, children who were obese
at 10-14 years had a 75% probability of being obese as adults.
Parental obesity was found to more than double the risk of adult
obesity among children under the age of 10 whether or not the children
were obese at that age.
Three innovations have been made in the treatment of myeloma in
the past 10 years: initial infusional chemotherapy, high dose treatment
with melphalan plus an autograft, and maintenance treatment with
interferon. These have dramatically improved the outlook for selected
patients, says a report in Bone Marrow Transplantation
(1997;20:435-43), but it adds that entry of patients into
national trials remains low.
Current guidelines in Britain and several other countries
recommend that all pregnant women should be tested for carriage of
hepatitis B virus, but only 16% of districts in England and Wales
follow the recommendation (Journal of Medical Screening
1997;4:117-27). Yet testing all women in their first pregnancy
would cost £540 000 a year in Britain, identify 1,140 carriers,
prevent 255 children becoming infected, and in time prevent 45
deaths from liver disease.
Minerva has enjoyed white water rafting in the rain forest
rivers of Costa Rica, so she was saddened to read in Morbidity
and Mortality Weekly Report (1997;46:577-9) an account of an
outbreak of leptospirosis among 26 Americans who had had a rafting
holiday there. Nine of the 26 had had an illness that met the case
definition of leptospirosis. The rivers had been flooded, which makes
infection more likely, but nevertheless the report is a bit
discouraging - advice to "minimise contact with potentially
contaminated water" will be hard to follow.
Examination of samples of chloroquine and antibiotics from
pharmacies and other drug outlets in Nigeria and Thailand found that in
both countries over one third of the drugs tested contained quantities
outside British pharmacopoeial limits (Tropical Medicine and
International Health 1997;2:839-45). Six substandard
preparations contained no active ingredients at all. The report blames
most of the deficiencies on poor quality assurance during
manufacturing.
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