4 August 2003

Wanted, dead or alive

Organ and tissue donors should receive tax breaks for their donation, just as other people can claim donations to charities in their tax returns; and, we should have an ethical market in human organs from living donors. Everyone else involved in transplantation gains significantly - why shouldn't the donors? These are two of many controversial ideas put forward in an issue of the Journal of Medical Ethics devoted to addressing the supply of organs for transplantation from both living donors and cadavers.
Other opinions up for debate are that no one should have the right to say what should be done to his or her body after death, and that the state should hold responsibility for human cadavers and determine their best disposition.

J Med Ethics 2003; 29: 125-202

Vitamin advice

Can vitamin supplementation prevent cancer and cardiovascular disease in patients with no known or potential nutritional deficiency? The US Preventive Services Task Force has reviewed the literature. Its clinical guidelines conclude that the available evidence is insufficient to recommend either for or against supplements of vitamins A, C or E, multivitamins with folic acid, or anti-oxidant combinations.1,2 However, the Task Force did advise against the use of β-carotene supplementation for this purpose, because of a known link to a higher incidence of lung cancer and all-cause mortality in heavy smokers.

1. Ann Intern Med 2003; 139: 51-55
2. Ann Intern Med 2003; 139: 56-70

Clinical skills protest

For nearly 40 years, US medical students haven't had to perform one-on-one bedside examinations as part of their Medical Licensing Exam -- they "got off" because of concerns about inconsistencies across the multitudes of testing sites and among different examiners, says a report in Texas Medicine. Now, considering that a doctor's ability to translate knowledge into practice is critical, a new Clinical Skills Examination has been proposed and trialled in the USA. It's a one-day affair in which each medical student is asked to examine 10 to 12 "standardised" patients (actors who have been extensively trained to ensure they will present to each medical student in exactly the same way) for about 15 minutes each. The cases cover common conditions that doctors are likely to encounter in a general ambulatory clinic.
The report said US medical students are opposing plans to introduce the new test because of the additional financial burden to them and a lack of evidence as to the new test's validity.

Tex Med 2003; 99(2): 26-29

No need for adrenaline

An Australian study has overturned the popular notion that treating bronchiolitis with nebulised adrenaline will shorten hospital stay, say North American editorialists.1 They were commenting on a randomised placebo-controlled
trial of 194 infants admitted to Queensland hospitals with bronchiolitis.2 Three 4 mL doses of 1% nebulised adrenaline given at
4-hourly intervals after admission did not significantly reduce length of hospital stay or the time to being ready for discharge, and did not alter respiratory rate or respiratory effort scores.
The editorialists said that perhaps doctors must recognise that no known treatment of bronchiolitis will reduce the length of hospital stay required.

1. N Engl J Med 2003; 349: 82-83
2. N Engl J Med 2003; 349: 27-35

Depressed in Africa

Group-based interpersonal psychotherapy (IPT) can reduce depression and dysfunction in impoverished, AIDS-stricken areas
of sub-Saharan Africa, say US researchers. They conducted a randomised, controlled trial of IPT
in 248 adult men and women from
30 villages in rural Uganda who had major or subsyndromal depression, using locally validated research tools. The intervention focused on four areas: grief, interpersonal disputes, role transitions and deficits (persistent problems in initiating
or sustaining relationships). The researchers found that the improvement in the villagers who received IPT was over and above that seen in villagers who did not. The successful intervention is now being offered to those in the control arm of the study.

JAMA 2003; 289: 3117-3124

Women's Health Initiative

Breast cancers linked to relatively short-term combined hormone therapy are more advanced and occur earlier than expected. Further, there is no easy way to identify those women at higher risk, and women receiving this therapy will have a much higher rate of mammographic abnormalities, say US experts.1 They were commenting on further analysis of the aborted Women's Health Initiative randomised controlled trial of more than 16 000 postmenopausal women, which suggested that such therapy may not only stimulate breast cancer growth but also hinder breast cancer diagnosis.2

1. JAMA 2003; 289: 3304-3306
2. JAMA 2003; 289: 3243-3253