Infertility treatment
A trial in the BMJ shows that neither clomifene citrate nor intrauterine insemination without ovarian stimulation is effective in treating unexplained infertility of 2+ years duration. This contradicts both an earlier meta-analysis, which showed a benefit from clomifene, and NICE guidelines, which recommend up to 6 cycles of intrauterine insemination without stimulation in couples with unexplained infertility. Despite these results, couples may be unhappy to be told ‘keep trying’. An accompanying Editorial suggests that if treatment is to be offered, IVF is the more cost-effective option.
Malaria protection in short-term travelers
A few weeks ago, Dr Lydgate mentioned that falciparum malaria was increasing in the UK, mainly in people of West African origin who go to visit family and friends. An article in the NEJM reviews malaria chemoprophylaxis and other preventative measures, and identifies readily accessible resources that will help doctors give appropriate advice. It discusses special circumstances (such as pregnancy) that need to be taken into account, and makes the important point that, since no chemoprophylactic regimen is 100% effective, travellers should receive clear instructions about what to do if fever develops after they’ve returned home.
Malaria worldwide
In a global context, malaria in travellers is a trivial problem compared to the burden of endemic disease. The Plasmodium falciparum parasite currently causes 500 million cases of malaria each year and over a million deaths. The Millennium Development Goals, established by the United Nations in 2000, included the target of reversing trends in the incidence of malaria by 2015, and stimulated substantial investment in prevention. A study in PLoS Medicine reckons that, on the whole, the allocation of funding has been appropriate, but draws attention to serious shortfalls in Southeast Asia and the Western Pacific.
PPIs and fracture
A study in the Canadian Medical Association Journal adds to the evidence that proton-pump inhibitors increase the risk of osteoporotic fracture, although the underlying mechanism remains uncertain. The odds ratios generated are fairly modest, but because fracture is so common, particularly in the elderly, this constitutes a significant public health issue. Although this study found an effect only after 5 years or more of use, an earlier study with larger numbers saw a significant effect after only 1 year, leaving the timescale of this adverse effect in doubt. As an accompanying Commentary says, physicians will need to balance risk and benefit carefully.
Unusual infections in immigrants
Melioidosis, caused by infection with Burkholderia pseudomallei, is found in northern Australia and parts of Southeast Asia, including Vietnam and the Philippines. Rather like the tubercle bacillus, B. pseudomallei can remain dormant for months or years, only to be reactivated when the immunity of the host is compromised. The clinical presentation is diverse, including cavitating pneumonia, soft-tissue infection, genitourinary infection and sepsis. A case report in the NEJM demonstrates that melioidosis is worth consideration when patients with puzzling chronic infections have lived in or visited regions where the disease is endemic.
Febrile seizures carry little long-term threat
Many clinicians know from experience that children who have a febrile seizure (a seizure during a febrile illness without intracranial infection or inflammation) generally have a good prognosis. However, hypotheses of lasting harm have persisted for decades. A longitudinal registry-based study from Denmark published in the Lancet does much to clarify the matter. Over the 2 years following a febrile seizure, the death rate approximately doubled (although still low in absolute terms). But on analysis, the increase was almost entirely confined to complex (>15 min or recurring) seizures, and probably reflects pre-existing neurological problems. The accompanying Comment puts the findings in context nicely.
Run for your life
Many people run regularly because they believe that it improves their health, and a longitudinal study in Archives of Internal Medicine suggests that they’re right. In 1984, the investigators recruited 500 people, all over 50 years of age who ran for an average of 4 h a week and a similarly aged healthy control group who didn’t run. Nineteen years later, 15% of the runners had died, compared with 34% of controls. Disability scores were also lower in the runners. Of course, people who choose to run when they are 50 years or older are a self-selected group likely to have a generally healthy lifestyle. Even so, the findings seem a convincing advertisement for the benefits of vigorous exercise.
Orphan diseases and moral quandaries
A thoughtful Observation piece in the BMJ considers ‘orphan diseases’ – those generally ignored by pharmaceutical companies. Some are poor commercial prospects because they affect very few people, others because although they affect many people, the vast majority of those afflicted are too poor to pay for treatment, a situation seen in some ethnic groups in the developed world as well as in developing countries. The author, whose adrenocortical carcinoma falls firmly into the first category of ‘orphan’, ponders the tension between these two definitions when it comes to resource allocation, and points out the difficulties in lobbying for neglected tropical diseases such as ascariasis and trachoma in an age when HIV, malaria and TB are getting all the headlines.