November 28, 2002
An Oral Agent against Visceral Leishmaniasis
Miltefosine has been shown to have activity against Indian visceral leishmaniasis, and this agent can be taken orally. This randomized trial in India compared miltefosine treatment with intravenously administered amphotericin B, the most effective standard treatment. The initial cure rate was 100 percent in both groups. After six months, 94 percent of the 299 patients in the miltefosine group were deemed to be cured. If left untreated, most patients with visceral leishmaniasis will die from the disease. Miltefosine appears to be as effective as amphotericin B, which must be administered parenterally. An effective oral agent should prove useful. Further studies are required in children.
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Mercury, Fish Oils, and Myocardial Infarction
It is uncertain whether mercury in fish may counteract the beneficial effects of its n–3 fatty acids. In this case–control study among men, after adjustment for levels of n–3 fatty acids and other coronary risk factors, an increased level of mercury in toenail samples was associated with higher risk of a first myocardial infarction. These findings suggest that high mercury content in some fish may diminish the cardioprotective effects of fish intake.
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Mercury and Coronary Heart Disease
This nested case–control study of a cohort comprising dentists and other health professionals assessed the association between toenail mercury levels and the risk of coronary heart disease. No significant association was found between mercury and coronary disease events overall. However, the authors note that the effects of elemental mercury (to which dentists are occupationally exposed) might differ from those of methylmercury found in fish. This study found no association between mercury levels and the risk of myocardial infarction, although a weak relation could not be ruled out.
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Neurologic Gait Abnormality as a Predictor of Dementia
Neurologic gait abnormalities such as an unsteady or ataxic gait are associated with several forms of non-Alzheimer's dementia. In this prospective study, investigators analyzed gait abnormalities in 422 subjects who were more than 75 years of age and had no evidence of dementia. During follow-up, dementia developed in 125 subjects. The presence of a gait abnormality at base line was a significant predictor of dementia (hazard ratio, 1.96), but the association was primarily with non-Alzheimer's dementia (hazard ratio, 3.51), rather than with Alzheimer's disease (hazard ratio, 1.07). Older patients who have neurologic abnormalities with effects such as an unsteady gait or a frontal gait are at increased risk for dementia — particularly dementia secondary to vascular disease.
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Medical Progress: Typhoid Fever
The largest burden of typhoid fever falls on the developing world. Because there is no simple diagnostic test for salmonella infections, the importance of typhoid is often underestimated. Complications include gastrointestinal bleeding, intestinal perforation, and encephalopathy. For decades, cheap, effective oral antibiotics have been available, but the situation is changing with the emergence of resistant organisms. With the new conjugate Vi vaccine, mass-vaccination programs may be an attractive option.
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Legal Issues in Medicine: Moral Progress, Mental Retardation, and the Death Penalty
In June 2002, the U.S. Supreme Court ruled that it is unconstitutional to execute mentally retarded criminals. This essay reviews this decision and describes its implications for physicians. As a result of the ruling, more physicians and psychologists will be asked to perform evaluations to determine whether criminals are eligible for the death penalty.
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