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Indian Journal of Medical Sciences, Volume 57, Number 7, July 2003, pp. 323- 328 PRACTITIONERS SECTION Code Number: ms03009 Books and news DOCKWAL C. CURRENT MANAGEMENT OF AIDS AND HIV INFECTION 1999, Popular Prakashan Pvt. Ltd. Mumbai 400 034. pp. 184 Price Rs. 200/- Acquired immune deficiency syndrome (AIDS) has become one of the greatest challenges facing mankind today. Students and clinicians need comprehensive but practical information about HIV and the diseases it causes. This book aims to provide the necessary overview. The book is divided into four sections. 1. dealing with general aspects of HIV infection, such as epidemiology, structure and life cycle of HIV, pathogenesis, diagnosis diagnosis and opportunistic diseases. 2. dealing with involvement of various organ systems in AIDS. 3. dealing with therapeutics of AIDS and use of antiretroviral agents. 4. dealing with prevention of HIV infection in health-care settings and the AIDS epidemic in India. This detailed book will be extremely useful for medical students and practicing clinicians. The book is moderately priced. FUTURE TRENDS IN VETERINARY PUBLIC HEALTH Report of the WHO Study Group World Health Organization, Technical Report Series, No. 907 2002, vii + 85 pages Since the publication of the report of a Joint FAO/WHO Expert Committee on Veterinary Public Health in 1975, many significant developments have occurred in this field. The present report of a WHO Study Group re-examines the role and functions of veterinary public health and its contribution to public health practice today and in the years to come. Since 1975, new emerging and re-emerging zoonotic diseases have acquired global significance for human health, and have required rapid responses from, and team-work between, physicians, veterinarians, and biologists. The veterinary sector has a long and distinguished history in contributing to the maintenance and promotion of public health. As health is multidimensional, health policy and practice should be inter-disciplinary and intersectoral. Therefore, the contributions of other sectors in particular agriculture, animal health and production, food industry, education, housing, public works and communications are vital. Such concerted action is particularly needed in developing countries with weak infrastructure and limited resources. This report reviews current and foreseen global changes for their potential implication on veterinary public health with regards to national and international policies, management of programmes and training. The report also provides recommendations for action in these areas. MEDICINE PRICES: New survey shows that medicines can be less expensive Better information on prices, price differences and the factors contributing to the final cost of a medicine are essential if governments and other medicine purchasers are to find ways of making medicines more affordable. For this reason, the World Health Organization (WHO) and Health Action International (HAI) released Medicine Prices, a pricing manual outlining how to collect data for thirty widely-used medicines to identify how prices for patients are determined. Medicine prices vary between countries and regions and historically, relatively little has been known about how those prices are determined. In developing countries, where poverty places medicines out of reach of one-third of the population, people who do have some access sometimes pay more than in industrialized countries for the same medicine. Most of this money is paid out-of-pocket, as health insurance is often lacking. The new manual proposes a price survey methodology, suggests how to analyse price data, and identifies broad policy options to achieve more affordable prices. In short, it will allow buyers and procurers of medicines to make more informed, cost-effective choices, and will contribute to global knowledge on medicine pricing. The manual offers a new approach to measuring the cost of medicine. Among other things, it encourages comparison of prices of innovator brand products with their generic equivalents. In field tests, 30 days of ulcer treatment with the innovator brand of ranitidine was found to cost the equivalent of 50 days' wages in Cameroon and 20 days in Kenya, while the generic ranitidine cost 24 and eight days' wages respectively. The manual also brings to light the difference between procurement price and consumer prices. The latter include mark-ups, taxes, tariffs and other charges. Pilot-testing the manual in Peru, for example showed that local cost add-ons raised the price of generic ranitidine from $2.90 for 20 tablets (improved price) to $7.20 (retail price). Even in Brazil where most medicines are domestically produced, taxes and retail mark-ups typically add over 40% to factory prices. Analysis of price components allows greater clarity as to whether price differences originate with manufacturers, local distribution systems, dispensing fees, taxes and other local factors. Field tests with the manual in a number of low- and middle-income countries show, for example that the consumer price of nifedipine, a drug used for hyper-tension, is six times higher in South Africa than in Brazil, with intermediate prices found in Ghana and the Philippines. It is not unusual for people in developing countries to pay more for medicines than consumers in industrialized countries, both in relation to their income and even in absolute terms. For instance, in 2000, lamivudine, used in the management of HIV/AIDS, was found on average to be 20% more expensive in Africa than in ten industrialized countries. Average income levels in Africa are about 2% of those in the high income industrialized countries, so the difference in affordability is severe. Data from the pilot studies are available on HAI's website at www.haiweb.org/medicine prices. 745 000 CHILDREN DIE OF MEASLES EACH YEAR, BUT ALL DEATHS ARE PREVENTABLE THROUGH A NOVEL, COMPREHENSIVE IMMUNIZATION STRATEGY WHO Backgrounder/5 May 2003 745 000 Children die of measles each year, but all measles deaths are preventable using a comprehensive immunization strategy Problem: Despite the availability of a safe, highly effective and inexpensive vaccine, measles affects over 30 million children and claims the lives of almost 750 000 each year more than half of them in Africa. Of all the vaccine-preventable diseases, measles remains the leading killer of children. Solution: The strategy for measles mortality reduction recommended by WHO/UNICEF provides children with two opportunities for measles immunization. The first opportunity is given at nine months of age through the country's routine immunization delivery system, and a second opportunity is provided through supplementary immunization activities conducted every three to four years to ensure that every child is protected. The comprehensive strategy has been extremely effective in a block of seven
southern African countries. Through its full implementation, Botswana, Lesotho,
Malawi, Namibia, South Africa, Swaziland and Zimbabwe have reduced measles
deaths to If implemented correctly the strategy could prevent a further 2.3 million child deaths in Africa over the next 10 years, markedly reducing the death toll form measles on the continent. Global commitments to measles reduction: There are two global goals related to measles mortality reduction. The 2000 UN Millennium Development Goals include a target to reduce the under-five mortality by two thirds by 2010. And the 2002 UN General Assembly Special Session on Children (UNGASS) established a resolution to reduce measles deaths by 50% by the year 2005 compared to 1999 levels. This year, a resolution to the World Health Assembly, on 24 May, will ask countries to contribute actively to the achievement of the UNGASS and Millennium Development targets without further delay. Funding Needs: WHO and UNICEF currently estimate that an additional US$ 200 million will be required to implement the comprehensive measles strategy over the next three years in the 45 priority countries that account for about 95% of global measles deaths. The funds would pay for the vaccines, safe injection materials, refrigeration equipment, transportation and personnel both to the strengthen routine immunization systems and to conduct the supplementary measles immunization activities. A dose of measles vaccine cost only US$ 0.25, including safe injection equipment. Of all health interventions, measles immunization carries one of the highest health returns for the money spent. ABSTRACT NOT SO BENIGN INTRACRANIAL HYPERTENSION That a common antibiotic, doxycycline, used to treat malaria, acne, and other infections could cause increased intracranial pressure is not a recent revelation. Other tetracyclic antibiotics such as minocycline and tetracycline have caused intracranial hypertension. Benign intracranial hypertension is a syndrome of signs and symptoms of increased intracranial pressure without causative lesions on images obtained by magnetic resonance imaging or computed tomography. It should be considered when anyone taking doxycycline begins to complain of a new headache. Corbett and Thompson made a plea to replace "benign" with "idiopathic," to set apart the idiopathic form of increased intracranial pressure from symptomatic forms, and to dispel the notion that condition is totally benign. What to call this syndrome is far from settled, but at present we diagnose the primary or idiopathic form in individuals in whom no cause can be found after careful questioning and clinical evaluation. The secondary forms of intracranial pressure should be characterized as intracranial hypertension due to venous thrombosis, or intracranial hypertension due to medication, such as doxycycline. The other major controversy concerns the cause of intracranial hypertension. One group posit that all forms of intracranial hypertension, idiopathic and secondary, are due to venous occlusion, or venous hypertension. However, others have shown that changes in the venous sinuses including venous hypertension may be secondary to the intracranial hypertension itself. King showed that if pressure of cerebrospinal fluid is reduced the venous hypertension disappears. How doxycycline causes intracranial hypertension is not known; however, case reports abound of increased intracranial pressure associated with drugs including tetracycline, minocycline and doxycycline. Most of what we know about benign intracranial hypertension concerns the idiopathic form. More common than previously recognized, idiopathic intracranial hypertension occurs in 10-20/100 000 obese women. This mean that idiopathic intracranial hypertension is as common among obese women as multiple sclerosis. The disorder affects women (7:1), who present with symptoms of intracranial hypertension (headache, diplopia, whooshing noises in the head) and signs of intracranial hypertension (papilloedema, palsy of the sixth cranial nerve). Ninety per cent of the patients are obese. In contrast, intracranial hypertension due to the tetracycline antibiotics (including doxycycline) occurs in both sexes, at almost any age, and without concomitant obesity. The symptoms and signs of intracranial hypertension, however, are the same. How quickly a person develops intracranial hypertension after ingesting doxycycline is unknown, but in the largest review of intracranial hypertension induced by minocycline, some participants had used the drug for up to a year before developing symptoms whereas others became symptomatic within two weeks. Some dispute whether tetracyclines cause intracranial hypertension at all since so many individuals are treated with the drug every year without developing intracranial hypertension. However, individual cases have been reported where stopping the drug resolved symptoms and signs of intracranial hypertension and restarting the drug brought recurrence of intracranial hypertension. No matter whether the disorder is idiopathic or secondary, it is known to be anything but benign. Corbett et al found that idiopathic intracranial hypertension often persists up to 41 years after the initial diagnosis, and that over 25% of patients have severe visual loss. Patients with secondary forms of intracranial hypertension such as those using doxycyline are also not immune to visual loss. In 12 patients with minocycline induced intracranial hypertension 25% had notable visual field loss. Therefore, patients who complain of headache after using doxycycline should be examined carefully, including their visual acuity, and formal testing of the visual fields. Funduscopy after dilating the pupils to look for papilloedema is mandatory. Treatment of the primary and secondary forms of intracranial hypertension is similar-reduce intracranial hypertension. While there are no randomised controlled trials to guide the choice of treatment most practitioners recommend acetazolamide and weight loss to treat primary idiopathic hypertension. In the secondary forms, correcting the underlying mechanism, for example, treating the venous thrombosis, or stopping the causative medication is indicated. If visual loss progresses despite optimal medical therapy (usually acetazolamide, methazolamide or furosemide (frusemide) in adequate doeses), consideration of optic nerve sheath fenestration or lumbar peritoneal shunt is warranted to prevent further visual loss. Risk factors for visual loss include a delay in diagnosis due to failure to diagnose the disorder, inadequate treatment, and delayed treatment. The outcome of increased intracranial pressure due to doxycyclines is generally good if recognised early, before vision has been affected seriously. Despite the many controversies, intracranial hypertension due to use of doxcycline does occur. Practitioners prescribing the tetracyclic antibiotics should be aware of the syndrome of increased intracranial pressure, and pay particular attention to the ocular fundus for papilloedema. Appropriate referral for visual testing including visual fields should be made, and treatment directed at stopping the drug, and instituting symptomatic treatment that lowers the intracranial pressure. BMJ 2003;326:613. INHALED GLUCOCORTICOIDS VERSUS LEUKOTRIENE RECEPTOR ANTAGONISTS AS SINGLE AGENT ASTHMA TREATMENT: SYSTEMATIC REVIEW OF CURRENT EVIDENCE Ducharme Objective To compare the safety and efficacy of anti-leukotrienes and inhaled glucocorticoids as monotherapy in people with asthma. Design Systematic review of randomised controlled trials comparing anti-leukotrienes with inhaled glucocorticoids for 28 days or more in children and adults. Main outcome measure Rate of exacerbations that required treatment with systemic glucocorticoids. Results 13 trials (12 in adults, one in children) met the inclusion criteria; all were in people with mild and moderate asthma. Leukotriene receptor antagonists were compared with inhaled glucocorticoids at a daily dose equivalent to 400-450 mg beclometasone dipropionate. Patients treated with leukotriene receptor antagonists were 60% more likely to suffer an exacerbation requiring systemic glucocorticoids (relative risk 1.6, 95% confidence interval 1.2 to 2.2; number needed to treat 26, 13 to 81). A 130 ml greater improvement (80 ml to 170 ml) in forced expiratory volume in one second and a 191/min greater increase (141 to 241) in morning peak expiratory flow rate were noted in favour of inhaled glucocorticoids. Differences in favour of inhaled glucocorticoids were also observed for nocturnal awakenings, use of rescue b2 agonists, and days without symptoms. Risk of side effects was no different between groups, but leukotriene receptor antagonists were associated a 2.5-fold increase risk of withdrawals due to poor asthma control (relative risk 2.5, 1.8 to 3.5). Conclusions Inhaled glucocorticoids does equivalent to 400 mg/day beclometasone are more effective than leukotriene receptor antagonists in the treatment of adults with mild or moderate asthma. There is insufficient evidence to conclude on the efficacy of anti-leukotrienes in children. BMJ 2003;326:623-3. DOCTORS & MEDICAL INSURANCE A quarter of 700 US jurors thought it was OK for doctors to lie to medical insurance companies to get them to fund treatments (Annals of Internal Medicine 2003;138:472-5). About a fifth said their doctor had already done it. Over half the respondents agreed with the statement: "My insurance company is more concerned with saving money than with improving and maintaining my health." BMJ 2003;326:720. Companies to get them to fund treatments (Annals of Internal Medicine 2003;138:472-5). About a fifth said their doctor had already done it. Over half the respondents agreed with the statement: "My insurance company is more concerned with saving money than with improving and maintaining my health." BMJ 2003;326:720 Copyright 2003 - Indian Journal of Medical Sciences. |
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