Minerva: November 1999
Women in Detroit can now get more than hot rollers and highlights at their weekly trip to the hair salon. In a campaign to cut high rates of hypertension, diabetes, and renal disease among the city's African-Americans, the National Kidney Foundation of Michigan is teaching stylists to spot suspicious symptoms and encourage their clients to see a doctor (Detroit News, 9 September 1999). The scheme could go nationwide if it is successful, although it's still unclear how women will respond to being probed about their health while trapped under a hair dryer.
The helicopter ambulance in Tromso, a rural area in north Norway, takes about 20 minutes to get airborne after an emergency call. Emergency medicine specialists estimate, however, that speeding up the take off would make little difference to the patients (Prehospital Immediate Care 1999;3:136-9). An expert panel reviewed 65 cases over two years - 51 deaths and 14 survivors with ongoing problems - and concluded that shortening the response time by 15 minutes would have improved the outcome in only two patients; a 6% increase in life years gained across the board.
Electroconvulsive therapy has been around longer than the randomised controlled trial, which may explain why there are still so few on the subject. The latest review found only 11 randomised trials and one meta-analysis published since 1987 (Medical Journal of Australia 1999;171:250-4). Only one of the trials tested electroconvulsive therapy against the newer selective serotonin reuptake inhibitors (and found it was faster and more effective). Other obvious gaps in the evidence include how best to prevent relapse of depression, and how to minimise memory disturbance.
Warfarin is relatively cheap and highly effective at preventing strokes in patients with atrial fibrillation, but study after study shows that doctors are reluctant to use it (Canadian Medical Association Journal 1999;161:493-7). In a Canadian cohort, only 87 out of 221 patients with atrial fibrillation received warfarin throughout the two years of the study. Those who did had a significantly lower rate of stroke than the others, suggesting that warfarin can work "in the wild" as well as within the controlled confines of a clinical trial. A decent qualitative study looking at doctors' and patients' attitudes to this drug would be illuminating.
Other health professionals taking over clinical duties traditionally performed by doctors is another recurring theme in the journals. This week, a randomised trial tests junior orthopaedic surgeons against specially trained physiotherapists in outpatients referred with musculoskeletal problems (Journal of Epidemiology and Community Health 1999;53:643-50). The physiotherapists achieved the same clinical outcomes as the trainees but took fewer x rays and referred fewer patients for surgery, saving the hospital substantial sums of money.
Most people with cancer agree that clinical trials are a good thing. Far fewer would offer to participate in one themselves, although a selection of oncology outpatients from Sydney reported that they would be more likely to take part if the trial were endorsed by a trusted health organisation (Health Expectations 1999;2:33-43). Knowledge about randomised trials remains poor: three quarters of the sample agreed with the statement, "In a clinical trial the doctor would make sure I got the best of the treatments."
It looks increasingly likely that a woman's diet influences her chances of survival from breast cancer (Cancer 1999;86:826-35). The latest data from the Nurses Health Study - a cohort of over 120 000 female nurses followed up since 1976 - suggests that protein from white meat and dairy products improves prognosis, although a leading commentator, and the authors themselves, acknowledge the drawbacks of this particular dataset. Meanwhile, randomised trials of low fat, high fibre diets are under way. The results will be available in about 2005.
Surgeons from Wisconsin persuaded 69 first year medical students to test their new computer based training module in a randomised trial (Surgery 1999;126:330-6). It made little difference to students' performance in a multiple choice exam, but it improved their technical skills such as knot tying and suturing more than did traditional didactic methods or a videotape. Disconcertingly, the authors call their educational initiative a treatment throughout the abstract, possibly because they think medical students' ignorance of surgery is some sort of illness.
The p53 gene and its protein are famous for inducing cell suicide, which helps to prevent cancers but also mediates the collateral damage caused by chemotherapy and radiotherapy. Scientists from Chicago have isolated a small molecule, pifithrin-|ga, which reversibly blocks p53's suicide potential, protecting mice from the lethal effects of overdoses of anticancer treatment without promoting the growth of tumours (Science 1999;285:1733-7). They hope the new compound, or others like it, will prove useful against the brutal side effects of some radiotherapy and chemotherapy regimens.
Regular sessions in a hot tub (whatever that is) could improve diabetic control in patients with type 2 diabetes, US researchers have found (New England Journal of Medicine 1999;341:924-5). They immersed eight volunteers in hot water for half an hour every day for three weeks and found their weight, fasting serum glucose concentration, and glycosylated haemoglobin concentration all went down. Less beneficial effects included being so dizzy on leaving the tub that participants were unable to walk straight.
A 31 year old man being treated for a testicular teratoma developed this distinctive, acute, itchy rash 2 days after his second infusion of bleomycin. His wife commented that it looked like he had been whipped. This unusual rash is typical of flagellate erythema due to bleomycin treatment, and in this case responded to a potent topical steroid. The rash and pruritis settled within two weeks, but the patient was left with some residual streaky pigmentation.
Imtiaz Ahmed, specialist registrar,
A Ilchyshyn, consultant, department of dermatology, Walsgrave Hospital NHS Trust, Coventry CV2 2DX
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studentBMJ 1999;07:394-436 November ISSN 0966-6494
