This week in the BMJ

Volume 326, Number 7383, Issue of 1 Feb 2003

[Down]Three step screening predicts dementia
[Down]Big baby girls have higher breast cancer risk
[Down]Sepsis treatment: one size does not fit all
[Down]Low doses of methotrexate can suppress bone marrow
[Down]Patients who see the same GP are more satisfied
[Down]Euthanasia is not just the doctors' domain
[Down]I passed the marriage medical

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)




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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.



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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.



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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.



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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.



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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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