MinervaBMJ 1996; 312 doi: https://doi.org/10.1136/bmj.312.7036.986 (Published 13 April 1996) Cite this as: BMJ 1996;312:986
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Each year 500000 women die of complications of pregnancy and childbirth, and 99% of these deaths occur in developing countries. More than one third of the fatalities are due to sepsis and abortion (Health Policy and Planning 1996;11:1-15). The most important action to reduce maternal deaths, says the report, would be to make abortion legal and freely available to all women. Deaths from haemorrhage could be substantially reduced by improving the nutritional status of women of childbearing age.
The American Cancer Society continues to recommend that mammography should be offered to women from the age of 40, despite lack of clear evidence that starting screening at this age reduces mortality. A report in the “American Journal of Surgery” (1996;171:356-9) gives some data said to support screening from the age of 40: in a consecutive series of needle biopsies after mammography there were 32 cancers in 219 women aged 40-49 and 184 cancers in 542 women aged 50 or over. Screening younger women picks up some cancers, but the rate is far lower than in those past the age of 50.
Arguing whether or not women under 50 should have mammography is to oversimplify the issue, according to a recent viewpoint article from Canada (Lancet 1996;347:881-2). The combined effects of the increase in incidence with age, changes in biology, and changes in the sensitivity of mammography act together to tip the balance somewhere between 40 and 55 years. The age at which screening should start should be decided for each individual woman, with account being taken of factors such as family history and the size of the breasts.
A controlled trial of the Charnley and Stanmore hip prostheses set up at the Royal National Orthopaedic Hospital is reported in the “Journal of Bone and Joint Surgery” (1996;78B:178-84). After 5-10 years' follow up 76 of the 413 patients had died. Only 16 revision operations were needed, nine on Stanmore and seven on Charnley prostheses. In 15 of these 16 cases the operation had been done by a trainee surgeon, though overall they had carried out only 54% of the procedures.
Not only does smoking have an effect on ulcerative colitis but so do nicotine patches. A double blind, placebo controlled randomised trial of nicotine patches in 72 patients with ulcerative colitis (Annals of the Royal College of Surgeons of England 1996;78:85-91) found that 17 of the 35 patients given nicotine went into full clinical remission as against nine of the 37 given placebo patches. Further evidence has shown that nicotine, like corticosteroids, is effective in inducing remission, but it does not seem much use in preventing relapses.
The Framingham study enrolled 5209 men and women aged 28-62 in 1948 and has examined them at two year intervals ever since. A report in “Archives of Internal Medicine” (1996;156:505-9) looked at those people who reached the age of 75. The three factors that determined long survival were smoking few or no cigarettes, having a low blood pressure, and having a high fixed vital capacity. Long lived parents also helped.
Follow up for 10 years of 152 patients with typical symptoms of reflux oesophagitis (Gut 1996;38:481-6) found that over 70% of the survivors still had heartburn and half were taking daily treatment to suppress acid. The report concludes that most patients found to have acid reflux at endoscopy will need long term treatment and that a controlled trial is needed to compare the results of surgery with those of medical management.
The current approach to the treatment of asthma is that the disease is an inflammatory disorder that often responds best to treatment with inhaled steroids. In theory this treatment has no or no serious side effects; but a report in the “Journal of the Royal College of Physicians of London” (1996;30:128-32) draws attention to the growing evidence that prolonged use of inhaled steroids reduces bone density. Once again, long term research studies will be needed to give long term reassurance.
A comparison of 982 patients admitted to the Henry Ford Hospital with acute myocardial infarction in 1981-4 with 816 patients admitted with infarcts in 1990-2 found that mortality in hospital was 14.7% in the first series but only 7.4% in the second (American Heart Journal 1996;131:250-6). The difference in mortality was attributed to changes in treatment—in particular, the increased use of β blockers, angioplasty, and thrombolytic drugs.
Two patients with diabetes were seen in this clinic with the same story. Both had neuropathy and were blind, and both had developed painless swelling of a foot after walking on uneven ground. Because of the lack of pain no radiographs were obtained for several weeks, by which time Charcot neuroarthropathy of the midfoot had developed. In patients with insensitive feet due to diabetic neuropathy the lack of pain should not provide any reassurance about the absence of serious disease, and poor vision may increase the risk of developing a Charcot joint.—J E SHAW, research fellow, J M BOULTON, professor of medicine, Manchester Royal Infirmary M13 9WL
Medical schools in the United States are responding to public demand by opening “mini-med schools”—classes aimed at teaching non-professionals about the discoveries of medical science (JAMA 1996;275:897-9). Over 20 institutions are offering classes; one example is the University of Chicago Medical Center, which has put 700 people on to its waiting list after filling its first intake of 300.
Elderly patients with Gram negative bacteraemia of urinary origin are often misdiagnosed as having a respiratory infection, says a report in “Age and Ageing” (1996;25:130-2). In a series of 104 patients the main presenting symptoms were confusion, cough, and dyspnoea; only one fifth had new urinary symptoms. Diagnostic delay may be avoided by obtaining a catheter specimen of urine on the day of admission.
A typical American woman is likely to want to become pregnant for only 15% of her reproductive years. Sex at other times carries two risks, unwanted pregnancy and sexually transmitted infections (American Journal of Epidemiology 1996;143:311-8). Unfortunately, the contraceptive methods with the best record of preventing pregnancy are the least effective in protecting against infections. The target should be the development of some method that will be really effective at both functions.
A discussion in “Addiction” (1996;91:325-37) of the J shaped relation between alcohol consumption and mortality makes the point that social factors also have a very J shaped relation with alcohol consumption. Very heavy drinking is a deviant behaviour, but so are abstention and very light drinking—and there are reasons why people in these groups are at variance with the main norm of their culture.