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| A dozen good ideas to battle hepatitis |
| The number of people living with chronic viral hepatitis is startlingly high: nearly half a billion people around the world, or one in 12 of the global population, are infected with hepatitis B or C. Even worse, most of them are not even aware they are infected. These two diseases combined kill up to 1·5 million people yearly. But hepatitis is not high on the global health-care agenda. In view of the scale of infection and the indifference, ignorance, and stigma surrounding the disease, a multi-pronged plan of action is needed. |
| MMC: “giving cholera to cure dysentery” |
| “The reputations of both the Department of Health and the leaders of the profession were severely diminished by the events of 2007”. So concluded the UK House of Commons Health Committee's inquiry into Modernising Medical Careers (MMC). The universal judgment is that MMC was an unmitigated disaster. But it is worse than that. MMC signified a critical breach of trust between the medical profession and the Government. |
| Cheaper HPV vaccines needed |
| In developed countries, the introduction of a vaccine against the human papillomaviruses (HPV) that cause cervical cancer has been fairly smooth. But in developing nations, where 80% of cervical cancer cases occur, vaccine roll-out has hit one big barrier: that of cost. Currently, Merck's quadrivalent HPV vaccine, Gardasil, is the most expensive childhood immunisation in the world, costing US$360 for the required three doses. GlaxoSmithKline's Cevarix is not much cheaper at about $335. |
| Ustekinumab for chronic plaque psoriasis |
| Psoriasis affects about 3% of the general population, and 30% of these patients have moderate to severe disease. The more severely affected patients have significant physical and psychological impairments that affect all aspects of life, often leading to severe depression. Marked comorbidities have also been associated with moderate to severe psoriasis. About a third of patients with psoriasis also have joint involvement, which ranges from morning stiffness to crippling psoriatic arthritis. |
| Chemotherapy for malignant pleural mesothelioma |
| Before 2003, chemotherapy for malignant pleural mesothelioma was based on phase II trials, many of which were underpowered, yielding median overall survival of 6–9 months. Consensus existed that cisplatin and gemcitabine was the best drug combination. Since 2003 we have seen three major randomised trials in malignant pleural mesothelioma, the latest by Martin Muers and co-workers in today's Lancet. These trials now provide the strongest possible evidence on how best to treat patients with unresectable malignant pleural mesothelioma. |
| Multiple myeloma: detecting the effects of new treatments |
| In 1969, chemotherapy was shown to improve survival compared with placebo in patients with multiple myeloma. In the ensuing three decades, many permutations and combinations of chemotherapy agents were tested in attempts to improve on these results. In 1998, a meta-analysis of data on individual patients in all available randomised trials concluded that none of the combinations introduced from the 1960s to the 1990s were better than standard treatment with melphalan and prednisone. Consequently, the natural history of myeloma had remained virtually unchanged. |
| Alchemy, the safer cigarette, and Philip Morris |
| 20 years ago Philip Morris, the manufacturer of Marlboro cigarettes, noted in its annual report to shareholders that the company accounted for just 7% of worldwide cigarette sales, but added determinedly that “since our share of most international cigarette markets is still far below our US level, we have considerable room for future growth”. The prophetic rise in Philip Morris' market share of current global cigarette sales to 15·6% has culminated in the March spinoff of Philip Morris International (PMI). This means that PMI, newly headquartered in Lausanne, Switzerland, is now an entirely separate corporation that is traded on the New York Stock Exchange, as is Altria, which is the parent entity of Philip Morris USA (as well as a new cigar acquisition, John Middleton). |
| Trastuzumab: possible publication bias |
| Publication bias is of increasing concern, entrenching the use of inferior treatments. This concern now extends to adjuvant trastuzumab (Herceptin) in women with early breast cancer that is ERBB2 (HER2) positive, because a key clinical trial has been only selectively published. As such, patients are being given an important treatment sequence that may be much less effective than currently thought. |
| Food commodity derivatives: a new cause of malnutrition? |
| Poverty causes malnutrition, but malnutrition also contributes to poverty through increased morbidity, impaired development in children, and reduced capacity for work and productivity in adults. In rich countries food is a relatively small part of household consumption (10–15%). But in poor countries many households (especially those of wage labourers and landless people) use a large share of their income (40% or more) to buy food, so food price rises adversely affect purchasing power by reducing real income. Staples account for most expenditure on food for the poorest people, so increases in price might reduce the amount and quality of food consumed, thus increasing the risk of malnutrition and its consequences. |
| Republican presidential candidate unveils health-care plan |
| John McCain entered typical Democratic turf last month by announcing plans to reform health care in the USA if he is elected as the country's next president. His blueprint is one that may prove popular with employers, but will it impress voters? Todd Zwillich reports from Washington, DC. |
| Alice Springs faces epidemic of stab injuries |
| Last year, researchers reported that Alice Springs had the highest known incidence of stab injuries in the world and that these attacks were only the tip of the iceberg of the violence in Aboriginal communities. Stephen Pincock visited the small town in central Australia to investigate. |
| Czechs open up about mental-health problems |
| Mental health is coming out from under the shadows in the Czech Republic, with more people now seeking professional help. But, despite this positive step, psychiatric care in the country is largely lagging in the past, with too much emphasis on hospitalisation. Katka Krosnar reports. |
| Book: Curing formerly fatal childhood cancers |
| When asked, in 1938, about a case of retinoblastoma in a child, New York cancer specialist Frank Adair recommended that the parents quietly take the child home to die. If it were his own child, he added, he would do the same. Adair's colleague at New York's Memorial Hospital, Cornelius Rhoads, termed such children “doomed”. From our modern perspective, such passivity in the face of childhood cancer, especially in the USA, seems inconceivable. |
| Book In Brief: Changes in cancer care |
| “Please let it be anything but cancer”, is a phrase that will be all too familiar to clinicians. Although it is no secret that cancer is most patients' worst-case scenario, what is less well known is how cancer treatment has progressed. In The Cancer Treatment Revolution, David Nathan outlines how recent developments in cancer management have improved the outlook for millions of people. |
| Profile: Twalib Ngoma: creating cancer care in Tanzania |
| Twalib Ngoma was a medical student when he suspected his father had cancer. The disease, gastric cancer with lymph node metastases, was at an advanced stage, and his father desperately needed palliative care. In Tanzania at that time, the capacity for such care was virtually non-existent. Horrified at the pain his father was forced to endure, Ngoma pledged to improve cancer care in his homeland. |
| Doctors at war |
| Service in the military can be a testing experience for doctors. A particularly jaundiced account of a clinical and managerial posting in World War I was provided by Lt Colonel Charles Myers, consultant medical psychologist to the British army in France. Prompted by the outbreak of war, in 1939, he sought to warn others about the pitfalls of military medicine in a book entitled Shell Shock in France 1914–1918. “On the 31 March 1919”, Myers recalled, “I was demobilised, not altogether unwillingly. For I was by now tired of the many difficulties and frustrations which had beset me in my four and half years' work. Before leaving the army, I appealed to the Director-General of Medical Services for some recognition on behalf of certain junior medical officers of the neurological service who to my knowledge had done brilliant and strenuous work in a most unostentatious manner [no distinctions were forthcoming]… With this farewell visit ended my medical work in the Army of the last Great War.” What was it about the military that left Myers so disillusioned and what, if anything, can be generalised from his experience? |
| Obituary: David Mason |
| Pioneer in the application of monoclonal antibodies to diagnosis of cancer. He was born in Sutton, UK, on Nov 30, 1941, and died in Oxford, UK, on Feb 2, 2008, after complications of surgery, aged 67 years. |
| Transport policy is food policy |
| We endorse the call for fair and sustainable solutions to tackle the causes of global food insecurity (April 26, p 1389), but argue for greater recognition of the importance of reducing the demand for transportation fuel in resolving the struggle for energy between people and cars. |
| Preoperative bowel preparation |
| Caroline Contant and colleagues' randomised trial of 1431 patients undergoing elective colorectal surgery (Dec 22, p 2112) represents a milestone in the discussion concerning preoperative bowel preparation. Even though the rate of intra-abdominal abscesses was slightly increased in the group not undergoing bowel preparation, the general incidence was low (4·7% vs 2·2%; p=0·02). All other endpoints including mortality, length of hospital stay, and reintervention rate showed no significant difference between the groups. Contant and colleagues' conclusion was that preoperative bowel preparation can safely be abandoned. |
| Preoperative bowel preparation – Author's reply |
| For a practising colorectal surgeon, it is very important to maintain clarity as to what you are trying to achieve when undertaking surgery. Most patients who undergo such surgery have colorectal cancer. The aim of the surgery is to cure the cancer, and secondarily to achieve this with the lowest possible morbidity and mortality. In minimising morbidity, there are a range of complications that need to be prevented, some more relevant and significant than others. |
| Ovarian cancer and oral contraceptives |
| The Collaborative Group on Epidemiological Studies of Ovarian Cancer (Jan 26, p 303) claim that hundreds of thousands of ovarian cancers are prevented by oral contraceptives. The basis for their calculations is that slightly fewer of the 23 257 women who developed ovarian cancer at an average age of 54 years had taken oral contraceptives an average of 18·6 years previously, and for slightly fewer months, than women without ovarian cancer. |
| Ovarian cancer and oral contraceptives |
| The meticulous reanalysis of the dataset of about 100 000 women by the Collaborative Group on Epidemiological Studies of Ovarian Cancer represents the most important evidence currently available on the use of oral contraceptives and the consequent incidence of ovarian cancer. The reported results are very encouraging and are used in the associated Editorial as evidence in favour of “a more widespread, over-the-counter access to a preventive agent that can not only prevent cancers but also demonstrably save the lives of tens of thousands of women”. |
| Over-the-counter access to oral contraceptives |
| We welcome the collaborative reanalysis of data showing that the combined pill prevents ovarian cancer. However, we are concerned that the accompanying Editorial advocates “widespread over-the-counter access” to oral contraceptives. |
| Legislation threatens trust in genetic counsellors |
| We are seriously concerned about the effects of the British Government's plans to prohibit the implantation of embryos that would develop into children affected by genetic disorders. Clause 13(9–11) of the Human Fertilisation and Embryology Bill was designed, for instance, to stop deaf people using preimplantation genetic diagnosis or gamete donation to have deaf children, but it will constrain all reproductive decisions. |
| Domestic violence against women in Nepal |
| Your World Report (Feb 16, p 547) states that Nepalese women generally have low socioeconomic status, making them vulnerable to domestic violence. Despite efforts to increase women's awareness of their rights, amend discriminatory laws, and provide shelters and policewomen's desks for victims, domestic violence continues to grow. Thus, social factors need to address improving women's status, according to the report. |
| Department of Error |
| Contant CME, Hop WCJ, van ‘t Sant HP, et al. Mechanical bowel preparation for elective colorectal surgery: a multicentre randomised trial. Lancet 2007; 370: 2112–17—In this Article (Dec 22/29), the “Role of the funding source” section was omitted. It should have read “There was no funding source or sponsor. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication.” The “Contributors” section was also omitted, and should have stated that “All authors participated in the data analysis and reporting stage of this manuscript, and had seen and approved the final version.” The “Conflict of interest statement” should have read “We declare that we have no conflict of interest.” |
| Efficacy and safety of ustekinumab, a human interleukin-12/23 monoclonal antibody, in patients with psoriasis: 76-week results from a randomised, double-blind, placebo-controlled trial (PHOENIX 1) |
| Interleukins 12 and 23 have important roles in the pathophysiology of psoriasis. We assessed ustekinumab, a human monoclonal antibody directed against these cytokines, for the treatment of psoriasis. |
| Efficacy and safety of ustekinumab, a human interleukin-12/23 monoclonal antibody, in patients with psoriasis: 52-week results from a randomised, double-blind, placebo-controlled trial (PHOENIX 2) |
| Ustekinumab, a human monoclonal antibody against interleukins 12 and 23, has shown therapeutic potential for psoriasis. This study assessed the efficacy and safety of ustekinumab in psoriasis patients and assessed dosing intensification in partial responders. |
| Active symptom control with or without chemotherapy in the treatment of patients with malignant pleural mesothelioma (MS01): a multicentre randomised trial |
| Malignant pleural mesothelioma is almost always fatal, and few treatment options are available. Although active symptom control (ASC) has been recommended for the management of this disease, no consensus exists for the role of chemotherapy. We investigated whether the addition of chemotherapy to ASC improved survival and quality of life. |
| Head and neck cancer |
| Most head and neck cancers are squamous cell carcinomas that develop in the upper aerodigestive epithelium after exposure to carcinogens such as tobacco and alcohol. Human papillomavirus has also been strongly implicated as a causative agent in a subset of these cancers. The complex anatomy and vital physiological role of the tumour-involved structures dictate that the goals of treatment are not only to improve survival outcomes but also to preserve organ function. Major improvements have been accomplished in surgical techniques and radiotherapy delivery. Moreover, systemic therapy including chemotherapy and molecularly targeted agents—namely, the epidermal growth factor receptor inhibitors—has been successfully integrated into potentially curative treatment of locally advanced squamous-cell carcinoma of the head and neck. In deciding which treatment strategy would be suitable for an individual patient, important considerations include expected functional outcomes, ability to tolerate treatment, and comorbid illnesses. The collaboration of many specialties is the key for optimum assessment and decision making. We review the epidemiology, molecular pathogenesis, diagnosis and staging, and the latest multimodal management of squamous cell carcinoma of the head and neck. |
| Prostate cancer |
| In developed countries, prostate cancer is the second most frequently diagnosed cancer, and the third most common cause of death from cancer in men. Apart from age and ethnic origin, a positive family history is probably the strongest known risk factor. Clinically, prostate cancer is diagnosed as local or advanced, and treatments range from surveillance to radical local treatment or androgen-deprivation treatment. Androgen deprivation reduces symptoms in about 70–80% of patients with advanced prostate cancer, but most tumours relapse within 2 years to an incurable androgen-independent state. The recorded incidence of prostate cancer has substantially increased in the past two decades, probably because of the introduction of screening with prostate-specific antigen, the use of improved biopsy techniques for diagnosis, and increased public awareness. Trends in mortality from the disease are less clearcut. Mortality changes are not of the same magnitude as the changes in incidence, and in some countries mortality has been stable or even decreased. The disparity between reported incidence and mortality rates leads to the probable conclusion that only a small proportion of diagnosed low-risk prostate cancers will progress to life-threatening disease during the lifetime of the patient. |
| From drugs to delirium |
| In July, 2007, at around 0740 h, a 36-year-old man was brought to our emergency department by his father, with whom he lived. Since his teens, the patient had misused several drugs, often concurrently: cough mixture, cannabis, zopiclone and other sleeping tablets, and a mixture of ketamine and ecstasy. He had been admitted to our psychiatric unit five times in the preceding 6 years: three times for drug-induced psychosis, and twice for detoxification. His admissions were becoming more frequent. The patient's father said that, on this occasion, the patient had suddenly become confused, at around 0640 h. He had wandered out of the toilet without his trousers or underpants on, and had knelt on the floor, his body resting against his bed. He had inappropriate and scanty speech. His father did not know what drugs the patient had been taking recently—other than zopiclone, which was prescribed. |