medical corner

Does Facial Sebum Excretion Really Affect the Development of Acne?

2005-11-29T21:46:00.000-08:00

It is generally accepted that the severity of acne is correlated with facial sebum secretion. However, previous studies on the relation between seborrhoea and the development of acne did not consider topographical differences in facial sebum secretion and used relatively vague acne severity grading systems.
Objectives: To elucidate the relation between topographical variations in facial sebum secretion and the severity of acne in women.

Acne is a disease of the pilosebaceous unit. The major pathogenic factors promoting acne are increased sebum production caused by androgen action, ductal hypercornification, colonization by Propionibacterium acnes, and inflammation.[1,2] Increased sebum production stimulated by androgens is nearly always the first listed pathogenic factor promoting acne. However, facial sebum secretion depends upon the topography of the face. For example, it is generally accepted that the T-zone is greasier than the U-zone.[3] The relationship between seborrhoea and development of acne has been discussed in previous studies.[4-10] However, in most studies the methods used for measuring sebum secretion were inconvenient and were not standardized, and topographical differences of sebum secretion in facial skin were not considered. To demonstrate a relationship between sebum secretion and the development of acne lesions, measurements should be made at different facial sites. Various grading systems have been used to assess acne severity, but there is no generally accepted quantitative system in use.[11] Lesion counts may be acceptable for representing acne severity, but the method is laborious, inaccurate and irreproducible.

In this study, we measured sebum secretion at five facial sites and counted acne lesions at these sites using a lesion counting method that we developed, to elucidate the relationship between facial sebum secretion and acne lesion development in women with acne with a view to determining whether increased facial sebum secretion causes acne lesions directly.
All controls and patients with acne were women in their third and fourth decades. The patients with acne were selected by one investigator. The inclusion criteria were: patients who had not taken isotretinoin or any other medication known to affect sebum secretion, and who had not received chemical peeling or any surgical treatment for acne within 6 months of study commencement. Patients unaware of their medication type were excluded. Regarding the normal controls, as it was difficult to find individuals who have never experienced acne, we included control subjects who reported never having had more than five acne lesions simultaneously at any time, and who had no visible acne lesions at the time measurements were taken.

Measurement of Sebum Secretion
Facial sebum secretions were measured using a Sebumeter® (SM815; C-K Electronics, Cologne, Germany). Five different facial sites were selected: forehead (mid-glabella), nose (the tip), right and left cheeks (the most prominent area of both zygomata), and chin (mental prominence). Sebum was collected from each site on a plastic strip using a constant pressure of 10 N for 30 s. Participants were asked not to use any cosmetics and not to wash within 2 h of measurements. Amounts of sebum secretion were recorded and mean facial sebum excretion (MFSE)[1] was calculated. Measurement areas were classified as follows: high sebum secreting zone (T-zone; forehead, nose and chin) and low sebum secreting zone (U-zone; both cheeks). All procedures were performed by the same investigator in a room at constant temperature (22 °C) and relative humidity (42%). Measurements were started in the summer of 2003, and repeated on the same volunteers at 3-monthly intervals. The patient facial skin types were determined using the sebum secretion guidelines supplied with the Sebumeter.® However, because these guidelines list reference values for individual measurement sites only, they could not be used directly for determining the skin types of the T-zone, the U-zone or the whole face (MFSE). Thus, we obtained new sebum secretion reference values for these areas by calculating the mean value for each location. The reference values used to evaluate the facial skin types are listed in Table 1 .

Clinical Digital Photographs and Lesion Counting
Three clinical photographs were taken of the patients with acne: en face, and right and left lateral profiles. All photographs were taken using a digital camera (DSC-F717; Sony, Tokyo, Japan). We divided the surface of the face into forehead, right cheek, left cheek, nose and chin areas. The boundaries of these areas were determined based on regional variations in sebum secretion (Figure 1). Acne lesions were classified as noninflammatory (noninflammatory comedonal papules) or inflammatory lesions (including inflammatory papules, pustules, nodules and cysts). Forehead, nose and chin acne lesions were counted using en face photographs. Right cheek and left cheek lesions were counted using the right and left lateral profile photographs, respectively. Digital photograph images were manipulated using digital retouching software: Jasc Paint Shop Pro 8.0 (Jasc, Eden Prairie, MN, U.S.A.). Noninflammatory lesions were marked with a gold circle and inflammatory lesions with an orange circle on photographs using the picture tube tool in Paint Shop Pro 8.0, and the numbers of each circle type were counted, not the lesions themselves, to avoid duplicated counting. An example for our acne lesion counting method using digital photography is shown in Figure 2. This work was done by agreement between three dermatologists, to minimize individual error with respect to lesion classification.

Statistical Analysis
Comparisons between patients and controls with respect to amounts of sebum secreted were evaluated using Student's t-test. The Wilcoxon rank sum test was used to compare subjects with dry skin types because sample sizes were insufficient for the Student's t-test. Comparisons of lesion counts for dry and normal skin types were done using Student's t-test. The strength of the association between sebum secretion and lesion number was evaluated using Pearson's correlation coefficients. P < 0.05 was considered to be statistically significant.

Sebum secretions in the whole face and in the T- and U-zones (areas of high and low sebum secretion, respectively) were higher in patients with acne than in controls. There was no correlation between sebum quantity and acne lesion count in most facial regions.

Increased levels of facial sebum secretion were observed in patients with acne. Our findings indicate that increased sebum levels do not directly cause development of acne lesions.

HIV/AIDS and the Flu

2005-11-29T21:37:00.000-08:00

HIV (human immunodeficiency virus) is the virus that causes AIDS (Acquired Immune Deficiency Syndrome). HIV kills or damages cells in the body’s immune system, gradually destroying the body’s ability to fight infection and certain cancers. An estimated 850,000 to 950,000 people are infected with HIV in the United States.

People with HIV/AIDS are considered at increased risk from serious influenza-related complications. Studies have shown an increased risk for heart- and lung-related hospitalizations in people infected with HIV during influenza season as opposed to other times of the year, and a higher risk of influenza-related death in HIV-infected people. Other studies have indicated that influenza symptoms might be prolonged and the risk of influenza-related complications higher for certain HIV-infected people. Vaccination with a flu shot has been shown to produce an immune response against influenza viruses in certain people infected with HIV.

Because influenza can result in serious illness, HIV-infected persons are recommended for vaccination. During the setting of the current vaccine shortage, people with HIV/AIDS are among the priority groups that should get flu shots this season. This fact sheet provides Questions & Answers to guide the administration of both flu shots and antiviral medications to people with HIV/AIDS.

This fact sheet provides Questions & Answers to guide both the administration of flu shots and antiviral medications in people with HIV/AIDS.

Should people with HIV/AIDS receive the inactivated influenza vaccine?

People with chronic underlying medical conditions, including HIV/AIDS, should receive inactivated influenza vaccine (the flu shot) during the 2004-05 influenza season. People with HIV/AIDS are considered at increased risk from serious influenza-related complications and should be vaccinated. Persons with advanced HIV disease may have a poor response to immunization. Therefore, chemoprophylaxis (use of antiviral medications for prevention) should be considered for these patients if they are likely to be exposed to people with influenza. (CDC has developed interim recommendations on the use of antiviral medications for the 2004-05 influenza season.

Are there people with HIV/AIDS who should NOT receive the inactivated influenza vaccine?

Contraindications to the use of inactivated influenza vaccine (the flu shot) in persons with HIV/AIDS are the same as those for uninfected persons ― a history of severe allergy (i.e., anaphylactic allergic reaction) to hens’ eggs, or a history of onset of Guillain-Barre syndrome during the 6 weeks after vaccination.

Can people with HIV/AIDS receive the live attenuated flu vaccine (LAIV, sold commercially as FluMist)?

No. Persons with HIV/AIDS and persons with other medical conditions are not recommended to receive the live influenza vaccine. LAIV contains a weakened form of the live influenza virus. LAIV is approved for use only among healthy persons between the ages of 5 and 49 years.

When should people with HIV/AIDS be prescribed antiviral medications for chemoprophylaxis (prevention)?

Persons at high risk of serious influenza-related complications should be given antiviral medications if they are likely to be exposed to other people with influenza. For example, when a family or household member is diagnosed with influenza, the exposed person with HIV/AIDS should be given chemoprophylaxis for 7 days. Vaccinated and unvaccinated HIV-infected persons who are residents of institutions experiencing an influenza outbreak should be given chemoprophylaxis for the duration of the outbreak or until discharge. People with advanced HIV disease who are not expected to mount an adequate antibody response to influenza vaccination should consider chemoprophylaxis with antiviral medications for the duration of influenza activity in the community, if antiviral medications are available in adequate supply locally. (CDC has developed interim recommendations on the use of antiviral medications for the 2004-05 influenza season.

There are no published data on interactions between anti-influenza agents such as amantidine and rimantidine and drugs used in the management of HIV infected persons. Patients should be observed for adverse drug reactions to anti-influenza chemoprophylaxis agents, especially when neurologic conditions or renal insufficiency is present.

Should health-care workers who have contact with HIV/AIDS patients be vaccinated?

Influenza vaccination is recommended for health-care workers who are involved in direct care of HIV- infected patients. More information about vaccination of health-care workers can be found in “Prevention and Control of Influenza Recommendations of the Advisory Committee on Immunization Practices (ACIP)”. Health-care workers who are healthy, less than 50 years of age, and are not pregnant may receive the nasal-spray flu vaccine (LAIV/FluMist).

Pandemic Influenza

2005-11-29T21:28:00.000-08:00

Pandemic Influenza: Worldwide Preparedness
Pandemic, avian, and seasonal flu are different.
Pandemic Flu: Currently there is no pandemic flu in the world. An influenza pandemic is a global outbreak of disease that occurs when three conditions are met: a new influenza A virus appears or “emerges” in the human population, it causes serious illness in people, and it spreads easily from person to person worldwide.
Avian Flu: Bird flu is an infection caused by avian (bird) influenza (flu) viruses. These flu viruses occur naturally among birds.
Seasonal Flu: Seasonal influenza (often called "the flu") is a contagious respiratory illness caused by influenza viruses and occurs every year. It can cause mild to severe illness. The best protection against seasonal flu is vaccination.

The single best way to prevent the flu is to get vaccinated each fall, but good health habits and antiviral medications are other measures that can help protect against the flu.

There are two types of vaccines:

The "flu shot"—an inactivated vaccine (containing killed virus) that is given with a needle, usually in the arm. The flu shot is approved for use in people older than 6 months, including healthy people and people with chronic medical conditions.
The nasal-spray flu vaccine—a vaccine made with live, weakened flu viruses that do not cause the flu (sometimes called LAIV for “Live Attenuated Influenza Vaccine”). LAIV is approved for use in healthy people 5 years to 49 years of age who are not pregnant.
Each vaccine contains three influenza viruses—one A (H3N2) virus, one A (H1N1) virus, and one B virus. The viruses in the vaccine change each year based on international surveillance and scientists’ estimations about which types and strains of viruses will circulate in a given year.

About 2 weeks after vaccination, antibodies that provide protection against influenza virus infection develop in the body.

When to Get Vaccinated
October or November is the best time to get vaccinated, but you can still get vaccinated in December and later. Flu season can begin as early as October and last as late as May.

Who Should Get Vaccinated
In general, anyone who wants to reduce their chances of getting the flu can get vaccinated. However, certain people should get vaccinated each year. They are either people who are at high risk of having serious flu complications or people who live with or care for those at high risk for serious complications.

People who should get vaccinated each year are:

1.) People at high risk for complications from the flu:

People 65 years and older;
People who live in nursing homes and other long-term care facilities that house those with long-term illnesses;
Adults and children 6 months and older with chronic heart or lung conditions, including asthma;
Adults and children 6 months and older who needed regular medical care or were in a hospital during the previous year because of a metabolic disease (like diabetes), chronic kidney disease, or weakened immune system (including immune system problems caused by medicines or by infection with human immunodeficiency virus [HIV/AIDS]);
Children 6 months to 18 years of age who are on long-term aspirin therapy. (Children given aspirin while they have influenza are at risk of Reye syndrome.);
Women who will be pregnant during the influenza season;
All children 6 to 23 months of age;
People with any condition that can compromise respiratory function or the handling of respiratory secretions (that is, a condition that makes it hard to breathe or swallow, such as brain injury or disease, spinal cord injuries, seizure disorders, or other nerve or muscle disorders.)
2.) People 50 to 64 years of age. Because nearly one-third of people 50 to 64 years of age in the United States have one or more medical conditions that place them at increased risk for serious flu complications, vaccination is recommended for all persons aged 50 – 64 years.

3.) People who can transmit flu to others at high risk for complications. Any person in close contact with someone in a high-risk group (see above) should get vaccinated. This includes all health-care workers, household contacts and out-of-home caregivers of children 0 to 23 months of age, and close contacts of people 65 years and older.

Is CDC recommending that flu shots go to “priority groups”, as was recommended last season?
To ensure that those who are at highest risk of complications from influenza have access to vaccine this season, CDC recommends that people in certain priority groups receive inactivated influenza vaccine (i.e., the “flu shot”) until October 24, 2005:

people aged 65 years and older, with and without chronic health conditions
residents of long-term care facilities
people aged 2–64 years with chronic health conditions
children aged 6–23 months
pregnant women
health-care personnel who provide direct patient care
household contacts and out-of-home caregivers of children less than 6 months of age
Beginning October 24, 2005, all persons can get a flu shot.

Use of the Nasal Spray Flu Vaccine
It should be noted that vaccination with the nasal-spray flu vaccine is always an option for healthy persons aged 5-49 years who are not pregnant. This vaccine is not subject to prioritization and can be given to healthy 5-49 year olds at any time.

People Displaced by Hurricane Katrina
Influenza vaccination is recommended for all people 6 months of age and older who have been displaced by hurricane Katrina and are living in crowded group settings. See http://www.bt.cdc.gov/disasters/hurricanes/katrina/vaccrecdisplaced.asp

Who Should Not Be Vaccinated
There are some people who should not be vaccinated without first consulting a physician. These include:

People who have a severe allergy to chicken eggs.
People who have had a severe reaction to an influenza vaccination in the past.
People who developed Guillain-Barré syndrome (GBS) within 6 weeks of getting an influenza vaccine previously.
Influenza vaccine is not approved for use in children less than 6 months of age.
People who have a moderate or severe illness with a fever should wait to get vaccinated until their symptoms lessen.
Vaccine Effectiveness
The ability of flu vaccine to protect a person depends on the age and health status of the person getting the vaccine, and the similarity or "match" between the virus strains in the vaccine and those in circulation. Testing has shown that both the flu shot and the nasal-spray vaccine are effective at preventing the flu.

Vaccine Side Effects (What to Expect)
Different side effects can be associated with the flu shot and LAIV.

The flu shot: The viruses in the flu shot are killed (inactivated), so you cannot get the flu from a flu shot. Some minor side effects that could occur are:

Soreness, redness, or swelling where the shot was given
Fever (low grade)
Aches
If these problems occur, they begin soon after the shot and usually last 1 to 2 days. Almost all people who receive influenza vaccine have no serious problems from it. However, on rare occasions, flu vaccination can cause serious problems, such as severe allergic reactions. As of July 1, 2005, people who think that they have been injured by the flu shot can file a claim for compensation from the National Vaccine Injury Compensation Program (VICP). For more information go to http://www.hrsa.gov/osp/vicp/.

LAIV: The viruses in the nasal-spray vaccine are weakened and do not cause severe symptoms often associated with influenza illness. (In clinical studies, transmission of vaccine viruses to close contacts has occurred only rarely.)

In children, side effects from LAIV can include:

- runny nose
- headache
- vomiting
- muscle aches
- fever

In adults, side effects from LAIV can include:

- runny nose
- headache
- sore throat
- cough

The therapeutic effects of meditation

2005-11-25T06:25:00.000-08:00

The conditions treated are stress related, and the evidence is weak

Meditation includes techniques such as listening to the breath, repeating a mantra, or detaching from the thought process, to focus the attention and bring about a state of self awareness and inner calm. There are both cultic and non-cultic forms, the latter developed for clinical or research use. The relaxation and reduction of stress that are claimed to result from meditation may have prophylactic and therapeutic health benefits, and a plethora of research papers purport to show this. However, this research is fraught with methodological problems, which I outline here, along with a short summary of the best evidence for the therapeutic effects of meditation in clinical populations. There is no Cochrane review on meditation.

Showing that certain physiological effects such as a slowed heart rate or a particular electroencephalo-graphic pattern occur during meditation and characterise a "relaxed state" may give insight into how meditation works but does not prove its therapeutic value. Most trials of the cumulative effects of meditation have had weak designs. Trials of transcendental meditation (a popular form of mantra meditation), when controlled at all, often compared self selected meditators with non-meditators or long term meditators with novices. These trials did not control for systematic differences between people who elect to learn the technique and those who do not, and between people who persist with the practice and those who abandon it. Randomised trials have often recruited favourably predisposed subjects so that expectations of benefit differ from control subjects. In trials of transcendental meditation for cognitive effects I found that positive outcome was confined to trials with subjects so recruited and to trials with passive controls such as "eyes closed rest." Trials with naive subjects and plausible controls (for example, pseudo-meditation) were negative. A similar association was previously found in a meta-analysis of cognitive behavioural techniques (including meditation) for hypertension.1 Other weaknesses have been use of multiple co-interventions, high attrition, and inadequate statistical analysis. Recent trials in clinical populations are slightly more rigorous but are limited in number.

Controlled trials of mindfulness meditation (detached awareness of experience) have all used co-interventions such as cognitive therapy and have largely not used active controls, so that specific effects cannot be isolated or separated from non-specific effects. Sahaja meditation (passive witnessing of thoughts) improved some outcomes in patients with poorly controlled asthma, but differences were not maintained at two months.2 People with epilepsy practising sahaja meditation showed a significant reduction in objective stress measures3 and frequency of seizures,4 but adequate intergroup comparisons are missing and there were marked differences in anxiety levels and frequency of seizures at baseline between groups. Added to a risk reduction programme for elderly men with hypercholesteraemia, Benson relaxation response (a non-cultic form of transcendental meditation) had no significant effect on blood lipids, weight, or blood pressure,5 and although patients with irritable bowel syndrome reported a reduction in symptoms after six weeks of practising Benson relaxation response, the only significant difference from waiting list controls was for flatulence.6

Transcendental meditation has been studied extensively, but most of the research continues to be carried out by researchers directly involved in the organisation offering transcendental meditation, who seem keen to demonstrate its unique value. A meta-analysis of trials of relaxation and meditation for trait anxiety included 70 trials of meditation and showed that the 35 trials of transcendental meditation were associated with significantly larger effect sizes than other techniques.7 However, it included uncontrolled trials, and its assertion that outcome was not sensitive to research design, type of control, or other confounders is not supported by any data. As it excluded studies of patients with psychiatric illnesses the relevance to clinical populations is unclear. An updated and independent meta-analysis of studies of meditation for anxiety is therefore much needed.

The meta-analysis of trials of cognitive behavioural techniques for hypertension showed that effect sizes were highly sensitive to procedures used for baseline measurements.1 Since then a trial using adequate baseline measures has reported that three months' practice of transcendental meditation significantly reduced clinic measured diastolic and systolic blood pressure over group controls given education.8 Progressive muscle relaxation produced an intermediate effect size. The mean adjusted changes in the transcendental meditation group were 10.7 mm Hg in systolic and 6.4 mm Hg in diastolic blood pressure. This and several other studies by authors associated with the transcendental meditation organisation indicate a positive effect on blood pressure, a claim that should be independently tested.

A trial reporting positive effects of transcendental meditation on exercise tolerance in men with coronary artery disease recruited favourably predisposed subjects, was not randomised, and had large baseline differences in exercise tolerance between groups that exceeded the reported effect sizes.9 The reported positive effect of transcendental meditation on the thickness of the intima media of the carotid artery, a measure of atherosclerosis, is confounded by co-intervention with diet, exercise, herbal supplements, and incomplete analysis of the data due to attrition and lack of funding.10 11 A small trial suggesting some benefit of transcendental meditation for asthma had serious problems related to compliance with the protocol.12 Evidence for the therapeutic effectiveness of transcendental meditation in other indications is either similarly flawed or confined to isolated small scale trials.

Overall, current evidence for the therapeutic effectiveness of any type of meditation is weak, and evidence for any specific effect above that of credible control interventions even more so. The only safety issue seems to be in seriously disturbed patients, in whom meditation may trigger psychotic episodes. The limited evidence that does exist is in indications where reduction of stress may have an important beneficial effect, and future trials with improved design may yet provide more concrete positive results in this area.

Improving Health in Developing Countries

2005-11-25T05:09:00.000-08:00

Improving health received considerable prominence in the millennium development goals. Three of the eight goals focused on reducing key causes of mortality in poor countries: maternal and perinatal conditions, diseases affecting children and infants, and the major communicable diseases. These remain priorities, although non-communicable diseases and injuries are increasingly important even in poor countries.Targets and indicators for each goal were developed to help monitor and evaluate progress. Tuberculosis is the only disease other than HIV and AIDS and malaria specifically mentioned in the last health goal.

Recognising that current and projected levels of funding are insufficient to provide even a minimum set of health services in low income countries has two implications.16 Firstly, if countries are to have any chance of achieving the millennium development goals, they need to re-evaluate existing strategies to determine whether more could be achieved with the resources already available. Indeed, they are likely to be able to achieve more immediately by replacing less effective strategies with more effective ones. Secondly, countries need to have a clear plan on how additional funds will be used to maximise their chances of attaining the goals. Improving efficiency may have an important additional pay-off; it is easier for countries to attract more external funding if they can show they use current resources well.
Most countries have the potential to achieve more with the available resources, by reducing waste and changing the activities.Some information on the effectiveness and costs of interventions targeting these conditions is already available.However, much of it has limited practical value to policy makers except in specific settings. Most studies have examined the cost effectiveness of different ways of spending small increases in resources. Although this is useful, it does not tell us whether the resources currently devoted to the conditions are being used as effectively as possible.

Another problem is that the studies have evaluated single interventions in isolation from other related activities that take place, or could take place, at the same time. Some have evaluated more than one intervention, but they have not typically considered the interactions that occur when interventions are conducted concurrently. This can provide misleading evidence. For example, both the effectiveness and costs of active case finding and treatment for malaria will depend on whether impregnated mosquito nets are widely used and whether there is a programme of indoor residual spraying with insecticide. The costs of undertaking two of these activities together cannot be assumed to be the sum of the costs of each intervention evaluated separately; nor can the effectiveness be summed, as is implicitly assumed in the existing literature. To provide practical information for priority setting, each intervention should certainly be evaluated individually, but then the joint costs and effects of undertaking interventions in various combinations should be incorporated.

Progress towards millennium development health goals: highlights

Child mortality—Reductions in child mortality slowed in the 1990s in sub-Saharan Africa and southern Asia.

These regions together account for over 80% of global child deaths.

Maternal mortality—Deaths have fallen substantially in countries with moderate to low levels of maternal mortality, but not in countries with the highest mortality. The chance of a woman dying during pregnancy or childbirth over her lifetime is as high as 1 in 16 in sub-Saharan Africa, compared with 1 in 2800 in the developed world.6

HIV and AIDS—Prevalence and deaths have increased in all regions of the world since 1990. In sub-Saharan Africa, 7 out of 100 adults are infected with HIV, and in some countries over 25% of the adult population is HIV positive. Although prevalence seems to have stabilised in the region since 2000, it remains high. This does not mean that the epidemic has been controlled, more that the increasing number of AIDS deaths each year roughly matches the number of new infections.9 Globally, 4.9 million people were newly infected with HIV in 2004 and 3.1 million died from AIDS

Malaria—Over a million die each year from malaria, most of them African children. Total deaths have increased since the late 1980s, probably because of the spread of drug resistant organisms across Africa.12 Prevention and treatment measures have improved recently, but this is yet to be translated into a reduction in deaths

Tuberculosis kills 1.7 million people a year. The number of new cases has been growing by about 1% a year, with the fastest increases in sub-Saharan Africa and the former Soviet states. In 2003, there were nearly 9 million new cases, including 674 000 among people with HIV. Less than half of cases are currently detected and treated

Most countries have the potential to achieve more with the available resources, by reducing waste and changing the activities.Some information on the effectiveness and costs of interventions targeting these conditions is already available.However, much of it has limited practical value to policy makers except in specific settings. Most studies have examined the cost effectiveness of different ways of spending small increases in resources. Although this is useful, it does not tell us whether the resources currently devoted to the conditions are being used as effectively as possible.

Treating severe and complicated MALARIA

2005-11-24T04:08:00.000-08:00

Clinical attacks are usually uncomplicated and can be managed with an effective oral drug. Most occur in sub-Saharan Africa. Of the 200 million episodes of clinical malaria that occur each year among African children, 4-6 million are severe and life threatening, and most of the 1 million deaths from malaria worldwide are in Africa. Although some risk factors for severe malaria have been identified—for example, human leucocyte antigens (HLA Bw 53 is associated with protection from severe malaria), it is still unclear why only some children develop severe disease.

The clinical manifestations of severe malaria are complex and may vary between age groups and according to the intensity of transmission that determines the speed at which partial immunity is acquired. Case management is also complex and is not limited to giving efficacious antimalarial drugs—it includes proper management of complications such as hypoglycaemia and metabolic acidosis.

Quinine remains the most widely used antimalarial drug in the treatment of severe malaria, but decreased sensitivity has been detected in areas of South East Asia.2Nowadays, drug resistance is probably the major problem for malaria control countries where malaria is endemic. This extract from Clinical Evidence defined chloroquine and sulfadoxine-pyrimethamine as drugs of "unknown effectiveness"; in the light of the widespread resistance to chloroquine and the emerging resistance to sulfadoxine-pyrimethamine, these two drugs should not be considered in severe cases.

Slow, constant intravenous infusion is the preferred route for giving quinine. This is not always possible and quinine can also be given by deep intramuscular injection into the anterior thigh. Intragluteal injection should be avoided because of the risk of sciatic nerve damage, and the absorption is slow and uncertain. A few studies have shown good efficacy and tolerability for rectal administration, without the problems of the intramuscular route or the complexity of intravenous administration.

In children able to attend a health facility that is well staffed and with adequate supplies, most deaths occur within 24 hours after admission, underscoring the importance of early treatment for preventing deaths. It is therefore important to improve access to appropriate care. One way of tackling this problem is to simplify the treatment by using rectal quinine or rectal artemisinin or artesunate, which could be given promptly even at basic health facilities. A trial on prompt administration of rectal artesunate is ongoing and should provide some data on its usefulness in early treatment.

Artemether is rightly classified among the interventions likely to be beneficial and has a marginal advantage over quinine. It is easier to use (intramuscularly) and is less likely to cause hypoglycaemia, but the cost of injections for treating an adult is about three times that of quinine. In settings with poor resources, cost has to be taken into account when drug policies are formulated. Nevertheless, the drug accounts for only a fraction of the total cost of managing cases of severe malaria. A careful evaluation is needed.

The new pope and medical ethics

2005-11-23T06:32:00.000-08:00

Can Benedict XVI strike a balance between Catholic doctrines and health?

Given that more than 37 million people world-wide are living with HIV, the late pope's opposition to the use of condoms attracted much criticism. Indeed, some critics blamed John Paul II directly for the loss of millions of lives from AIDS in Africa, where the Catholic church is flourishing; 2.3 million died in 2004 in sub-Saharan Africa alone. The new pope, Benedict XVI (formerly Joseph Ratzinger), also comes from the conservative wing of his church and is therefore very likely to endorse the encyclical of Pope Paul VI that bars Catholics from using any kind of artificial contraceptive. But what do we really know of his views on condom use and other medical and ethical issues?

As a cardinal, Joseph Ratzinger led the Congregation for the Doctrine of the Faith, an organisation descended from the holy inquisition. He worked closely with Pope John Paul II and was known to share many of his views. Three years ago Ratzinger wrote that "there are final boundaries we cannot cross without turning into the agents of destruction of creation itself."Indeed, in his first homily as pope he stated that he would continue to underline unequivocally "the inviolability of human beings, the inviolability of human life from conception to natural death."In response to the papal election the former Anglican archbishop of Cape Town, Desmond Tutu, said, "We would have hoped for someone more open to the recent developments in the world, the ministry of women, and a more reasonable position with regards to condoms and HIV/AIDS."

Yet Cardinal George Cottier, one of the Vatican's most influential theologists, supports the use of condoms as defence against HIV in special cases. Furthermore, Cardinal Lozano Barragan, effectively the Vatican's minister of health, has said that a spouse has the right to use a condom or oblige their marriage partner to do so in self defence against HIV infection. Will Benedict XVI accept and even develop this revolutionary idea for Catholics?

The defence of life is an essential Catholic philosophy, enshrined in the most influential and controversial encyclicals signed by past leaders of the Roman Catholic church: Humanae Vitae of Paul VI (1968) and Evangelium Vitae of John Paul II (1995).

The Catholic church is traditionally against abortion, which it sees as a contravention of moral law, with the legal status of the unborn child starting at conception. The church is also against euthanasia, which it considers to be a form of murder. Might the Vatican allow the condom's ability to defend life, albeit only within marriage, to take priority over its ability to prevent conception?

The Catholic church opposes the use of stem cells derived from the human embryo. It is not, however, against scientific progress and supports some controversial recent advances such as adult stem cell research and xenotransplantation, despite their ethical problems. The Vatican supports organ transplantation, and it sets ethical limits only around any related loss of human dignity, the use of the body as "a container" of organs, and any failure to use objective criteria to confirm the death of the donor.

Ratzinger wrote three years ago: "It is legitimate to accept the culture of transplanted tissue and donation of organs spontaneously and in all conscience" and also declared: "I enrolled in the organisation (for organ donors) years ago and carry the paper saying that my organs will be made available to whoever may need them. It's a sign of love."

Since becoming pope, Joseph Ratzinger has not made a direct statement on the use of condoms to protect against HIV. His previous views on pro-life issues worry many observers, particularly those campaigning for better health in less developed countries, but it may be unfair to judge him only on the basis of his past opinions. It is still not clear whether, and by how much, the Catholic church is interested in abandoning its traditional pro-life position. This seems unlikely to happen, given the recent support by Pope Benedict XVI to calls for a boycott of an Italian referendum on fertility rules. Nor is it clear whether a change in the pope's position on condom use would change the behaviour of many of the more than one billion Catholics around the world.

How is Diabetes diagnosed?

2005-11-23T05:27:00.000-08:00

The ADA recommends that all individuals age 45 and above, particularly those with a BMI equal to or greater than 25, should be tested for diabetes, and if the test is normal, they should be re-tested every three years. Testing should be conducted at earlier ages and carried out more frequently in individuals who have any of the following diabetes risk factors:
are overweight (BMI equal to or greater than 25)
have a first degree relative with diabetes (i.e., parents or siblings)
are members of a high-risk ethnic population (African American, Hispanic American, Native American, Asian American or Pacific Islander)
have delivered a baby weighing more than 9 pound or have had gestational diabetes
have HDL cholesterol levels equal to or less than 35 mg/dl and/or a triglyceride level equal to or greater than 250 mg/dl
have high blood pressure
on previous testing, had impaired glucose tolerance or impaired fasting glucose.

The ADA recommendations for diagnosing diabetes state that patients should be told they have diabetes if any of the criteria below applies:
Fasting plasma glucose is equal to or greater than 126 mg/dl;
Diabetes symptoms exist and casual plasma glucose is equal to or above 200 mg/dl; or
Plasma glucose is equal to or greater than 200 mg/dl during an oral glucose tolerance test.

If any of these test results occurs, testing should be repeated on a different day to confirm the diagnosis. If a casual plasma glucose equal to 200 mg/dl or above is detected, the confirming test used should be a fasting plasma glucose or an oral glucose tolerance test.

The future of men and their health

2005-11-23T05:06:00.001-08:00

Are men in danger of extinction?

It may seem incredible now, but up to just 25 years ago there was very limited research specifically targeted at women's health. The world seemed to assume that, except for issues related to reproduction, women's health problems, needs, and solutions were essentially the same as men's. As a result of vigorous lobbying by women from all over the world, research on women's health needs mushroomed in less than three decades. Major studies are now generating increasing evidence on important differences between men and women, from the cellular to the societal level.

Almost by default, the strong emphasis on women's issues (which we applaud and support) has revealed areas of men's health that require just as much attention. Perhaps one of the most puzzling is the difference in life expectancy between men and women. Despite having had most of the social determinants of health in their favour, men have higher mortality rates for all 15 leading causes of death and a life expectancy about seven years shorter than women's. Men's reluctance to embrace preventive strategies has also contributed to the spread of AIDS, particularly in Africa,and to an alarming rise in infections among young men, including other sexually transmitted diseases. Furthermore, there is a sustained increase in psychosocial disorders in men, including alcohol and substance abuse, mid-life crisis, depression, and domestic violence. Men's increasing aggression and autoaggression remain an unsolved health and societal problem. As you read this, over 30 wars and conflicts rage around the world, mostly created, maintained, and aggravated by men.

Can something be done to improve men's life expectancy? Are there effective and morally acceptable strategies to modify men's negative behaviour towards themselves and others? We hope that these questions and the need to answer them trigger a strong movement in support of more focused and stronger research on men's health.

Although there is still a long way to go in most societies around the world, it is clear that women can perform (and on most occasions outperform) pretty much all the tasks traditionally reserved for men. In most of the developed world women are starting to outnumber men in medical schools and making rapid gains in terms of equality in compensation and opportunities in the workforce. Will we see the gap in life expectancy between men and women widen as the gaps in social determinants of health become narrower? The answer is probably yes, unless women continue to adopt the same negative behaviours that characterise men today.

With the advent of sperm banks, in vitro fertilisation, sex sorting techniques, sperm independent fertilisation of eggs with somatic cells, human cloning, and same sex marriages, it is also reasonable to wonder about the future role of men in society. In a recent article a female Canadian journalist posed the question: "Are men the new women?" This question was motivated by the proliferation of magazines and television shows aimed at men with contents and formats that mirror what has been typically regarded as "women's stuff."What will be the implications of the redefinition of men's roles within the family, work, and society on their health? Will men be needed at all?

Are men and society prepared for the population explosion led by the Baby Boomers and by their "global ageing"? What will be the consequences of rapid fertility declines in the "post-Boomer" phase? Does hormone replacement therapy have a role in men? The Men's Health Report of Vienna 1999 and the World Health Organization report, Men, Aging and Health, published in 2000, provide a good starting point to look at the priorities and specific strategies that will be required to improve and maintain ageing men's health in a rapidly changing world. There is an urgent need to advertise and promote men's health in a positive way. In addition, gender specific training of primary care workers must be supported.

We see this theme issue of the BMJ as a great opportunity to invite the international community to reflect about men's health and the opportunities it creates for transdisciplinary activities. These span from basic research on sex and gender differences to new strategies of public health and health promotion, targeting men of all ages, with special emphasis on life course, high risk periods, environmental factors, and risk factor epidemiology.