Road trauma: who should be counted?

Fatalities associated with the use of road vehicles, as reported in two separate data series, are compared. The customarily used collection, Road Traffic Accidents Including Casualties, underreported the actual total of road trauma deaths in Australia for the decade 1965 to 1974 by almost 2000 cases (5.8%). Of this total, approximately half were attributable to duration of survival exceeding 30 days; the remainder could be accounted for by a quirk of definition which excluded "off-road" accidents (in car parks, domestic and farm premises, factories and shopping centres). Cases excluded increased from 1.7% in 1965 to 8.4% in 1974. In the interests of accurate countermeasure evaluation, some revisions are recommended.     

How should GPs be paid?

We need evidence that can underpin fundamental change.     

Infectious health care workers: should patients be told?

The risk of transmission of HIV or hepatitis B from infectious health care workers to patients is low. However, inadvertent exposure causes great concern amongst patients of an infected health care worker.

The patients of a Scottish dentist diagnosed hepatitis B e antigen positive were informed by letter of their exposure. A sample of patients was sent a postal questionnaire. Most (56%) respondents reported feeling anxious on receiving the letter but almost all (93%) thought patients should always be informed following treatment by an infectious health care worker, although the risk was very small.

We discuss clinical and ethical factors relating to informing patients following exposure to an infectious health care worker. We suggest that a balance should be struck between patients' wishes to know of risks to which they have been exposed, however small, and the professional view that when risks are negligible, patients need not be informed.

Key Words: Disease transmission - professional to patient • health personnel • dentists • patient information • truth disclosure • hepatitis B • HIV

     

When should conscientious objection be accepted?

This paper makes two main claims: first, that the need to protect health professionals' moral integrity is what grounds the right to conscientious objection in health care; and second, that for a given claim of conscientious objection to be acceptable to society, a certain set of criteria should be fulfilled. The importance of moral integrity for individuals and society, including its special role in health care, is advocated. Criteria for evaluating the acceptability of claims to conscientious objection are outlined. The precise content of the criteria is dictated by the two main interests that are at stake in the dilemma of conscientious objection: the patient's interests and the health professional's moral integrity. Alternative criteria proposed by other authors are challenged. The bold claim is made that conscientious objection should be recognised by society as acceptable whenever the five main criteria of the proposed set are met.     

Essential nutrients: food or supplements? Where should the emphasis be?

Alice H. Lichtenstein, DSc; Robert M. Russell, MD

JAMA. 2005;294:351-358.

The consumption of adequate levels and proper balance of essential nutrients is critical for maintaining health. The identification, isolation, and purification of nutrients in the early 20th century raised the possibility that optimal health outcomes could be realized through nutrient supplementation. Recent attempts using this approach for cardiovascular disease and lung cancer have been disappointing, as demonstrated with vitamin E and beta carotene. Moreover, previously unrecognized risks caused by nutrient toxicity and nutrient interactions have surfaced during intervention studies. The most promising data in the area of nutrition and positive health outcomes relate to dietary patterns, not nutrient supplements. These data suggest that other factors in food or the relative presence of some foods and the absence of other foods are more important than the level of individual nutrients consumed. Finally, unknown are the implications on public health behavior of shifting the emphasis away from food toward nutrient supplements. Notwithstanding the justification for targeting recommendations for nutrient supplements to certain segments of the population (eg, the elderly), there are insufficient data to justify an alteration in public health policy from one that emphasizes food and diet to one that emphasizes nutrient supplements.

     

Why do some people look older than they should?

BACKGROUND—As a component of studies on biological age, the age of subjects from their appearance (perceived age) was estimated.
OBJECTIVE—To determine the factors associated with looking older.
METHODS—Cross sectional study of London civil servants (318 men, 129 women) in the Department of the Environment study. Perceived age was recorded by an observer and the difference between this age and chronological age was analysed according to 20 different variables.
RESULTS—Men had an average perceived age of 0.37 years older than their actual age and women a perceived age of 0.54 years younger. In men, looking older was related to greying of the hair, grade of arcus senilis, and grade of baldness. Less expected, looking older was positively related to total serum cholesterol (p=0.03) and blood haemoglobin (p<0.01). In women, looking older was related to greying of the hair, positively to blood erythrocyte sedimentation rate (ESR), and negatively to serum bilirubin (p=0.01). Looking older was not related to alcohol consumption, employment grade, serum high density lipoprotein cholesterol, glucose, albumin, and calcium in either sex.
CONCLUSION—The relationships between looking older and total cholesterol and haemoglobin in men and ESR and bilirubin in women, require further investigation.
     

Communicating prostate cancer risk: what should we be telling our patients?

Until definitive evidence of the effectiveness of prostate cancer screening is available, most guidelines advocate that men make their own decisions about testing, after being fully informed. A man's perception of his personal risk is a key element in the decision-making process. In this decision-making, the current routine use of population risk estimates may be misleading. Risk estimates need to be relevant to the man making the choice. In particular, they should be age-specific and, where possible, include adjustments for known risk factors such as family history. As an example, although the population risk of lung cancer mortality is twice that of prostate cancer, for a non-smoking man with a family history of prostate cancer the direction of this comparison would be reversed. A man aged 50 diagnosed with prostate cancer has a greater likelihood (60%) of dying prematurely (before 80 years) from prostate cancer than a man diagnosed when aged 70 (38%). This can be attributed to the longer time available for the prostate cancer to progress, and the increased effect of competing causes of death among older men. This suggests that the oft-used statement "men are more likely to die with prostate cancer than from prostate cancer" is misleading, particularly for men diagnosed in their 50s or 60s. Decisions need to be made by men based on the best possible understanding of their personal vulnerability, and the individualisation of risk provides a more realistic appraisal of potential threat posed by the disease.     

Antiplatelets in secondary stroke prevention: should clopidogrel be the first choice?

Antiplatelet therapy has proven efficacy in the secondary prevention of recurrent non-cardioembolic ischaemic stroke. Recent evidence suggests clopidogrel is as effective as combined therapy with aspirin and extended-release dipyridamole for the prevention of recurrent stroke. As cerebrovascular and ischaemic heart disease are closely related, it would be sensible to use a drug shown to prevent vascular events in both territories. Clopidogrel meets these criteria, is superior to aspirin monotherapy, and has fewer side effects compared with extended-release dipyridamole. While there is no direct evidence supporting the use of clopidogrel in transient ischaemic attacks, it is likely that clopidogrel is effective because transient ischaemic attacks and stroke are part of the same disease spectrum. Clopidogrel could thus be useful as first line secondary prevention therapy in all non-cardioembolic stroke subtypes and transient ischaemic attacks, to prevent recurrent ischaemic events in all vascular territories.     

Infectious complications in children with nephrotic syndrome: Can they be prevented?

BackgroundSixty percent of children with nephrotic syndrome have frequently relapsing or steroid-dependent course. Serious infections like peritonitis, cellulitis, pneumonia etc. and anasarca with reduced urine output and complications there of including acute kidney injury and thromboembolism contribute significantly to morbidity and mortality in these children.MethodsQuestionnaire-based module to study infectious complications in children with nephrotic syndrome was circulated through survey monkey portal to paediatric nephrologists in our country. Twenty-two responded. Forty percent said that they saw patients with severe infections once a month. Fish bone analysis conducted on such patients reporting to our centre over next 3 months revealed that only 22% regularly monitored urine protein by dipstick. We proposed that reduction in time to report relapse by regularly monitoring urine protein could reduce complications in these children. Six urine protein dipsticks were handed over to patients who presented >7 days since relapse or with severe infection or anasarca in the last 1 year. These children were followed up for the next 1 year and given six more urine dipsticks every 3 months.ResultsTwenty-three patients were given urine protein dipsticks. Nine of them had 12 severe complications in the previous 6 months. None had any serious infections/anasarca on follow-up. Sixteen new patients had 14 serious complications in this time.ConclusionsEarly detection of relapse by home monitoring of urine protein by dipsticks was effective in significantly reducing the number of patients with severe infections and anasarca with reduced urine output.