This week in the BMJ
Volume 326, Number 7383, Issue of 1 Feb 2003Three step screening predicts dementia
Three step screening predicts dementia
A three stage screening procedure predicts development of
Alzheimer's disease and dementia three years later. In a population based study of 1435 elderly people, Palmer and colleagues (p 245) tested the procedure, which consists of a single question about memory
problems, assessment of global cognitive function, and neuropsychological tests. Over 85% of participants who had impairment at all three stages developed dementia after three years. However, sensitivity was low and only 18% of those who developed dementia were
identified: half of those who went on to develop dementia had reported
no problems with their memory and were therefore not included in the
next stages.
(Credit: WILL AND DENI MCINTYRE/SPL)
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Big baby girls have higher breast cancer risk
Women who were large for gestational age at birth are at increased risk
of developing breast cancer before the age of 50. Using a longitudinal
cohort of more than 5000 women with data on several birth
characteristics, McCormack and colleagues (p 248) found that their
length and head circumference at birth, adjusted for gestational age
and adult risk factors, were strongly associated with breast cancer
before (but not after) menopause. The association of larger size at
birth with an increased risk of premenopausal breast cancer should be
considered, the authors say, in light of its opposite association with
ischaemic heart disease.
(Credit: ANTONIA REEVE/SPL)
Sepsis treatment: one size does not fit all
Severe sepsis and septic shock are life threatening consequences
of infections and are the leading causes of death in intensive care
units. On page 262 Bochud and Calandra discuss the epidemiology, origins, and treatment of sepsis, which occurs when immune response to
invasive pathogens is poor. Gram negative, Gram positive, and fungal
infections account for the most cases, and over the past decades little
impact has been made in reducing mortality. Future treatment
possibilities include pathogen specific regimens, rather than "one
size fits all" strategies.
Low doses of methotrexate can suppress bone marrow
Low dose methotrexate is a preferred treatment in rheumatoid arthritis,
as well as treatment for psoriasis. It is usually effective and well
tolerated and may even prolong survival in patients with rheumatoid
arthritis. However, it can be associated with life threatening bone
marrow suppression, particularly when taken in combination with
trimethoprim or certain other drugs, or when a dosage error is made.
Sosin and Handa (p 266) present three cases of these complications,
including one which resulted in death, and remind doctors to check for
interactions when prescribing any other drug for patients
receiving methotrexate. Regular monitoring of blood counts is helpful
in picking up some cases of early toxicity but may not prevent all
episodes of bone marrow suppression.
Patients who see the same GP are more satisfied
Standards set by patients for access to and continuity of care in
general practice are higher than government targets. In a secondary
analysis of quality surveys, Bower and colleagues (p 258) found that
patients wanted next day appointments, waits for consultations of no
more than 6-10 minutes, and to be seen regularly. Patients' standards,
however, varied by the methods used and their sociodemographic group.
Setting standards in primary care must take account of the potential
tension between improving access and continuity and ensuring quality in
other areas, such as clinical and interpersonal care.
Euthanasia is not just the doctors' domain
Switzerland has an unusual position on assisted suicide: it is
legally acceptable if done for altruistic reasons and can
beconducted by non-physicians. Hurst and Mauron (p 271)
discuss the continuing debates on the legal aspects of euthanasia, the
compatibility of voluntary death with traditional medical practice, and
the participation of lay people as well as doctors. They contend that, to inform the continuing controversy, more research on public attitudes
and clinical practices at the end of life is needed.
I passed the marriage medical
Couples in China must pass a medical examination before being
allowed to wed. On page 277 Hesketh, who was married in China, recounts her test for marriage fitness, which consisted of a detailed family history, public pelvic examination, and peeing outdoors in a
cup. Ten years later, she visited 10 hospitals across China and
observed examinations, examined records, and interviewed participants. Though medical screening for marriage can be inconvenient and expensive, potentially unethical, and subject to charges of eugenics, its benefits include the chance to diagnose unrecognised diseases and
provide health education.
(Credit: XINHUA/AP)
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