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HIV success story

  1. Top of page
  2. HIV success story
  3. Repeat caesarean section or vaginal birth after caesarean section?
  4. Emergency contraception
  5. Bandwagoning health
  6. Colorectal cancer
  7. Cervical cancer
  8. Testicles
  9. Screening or prevention?

Ex-patients can help patients. Those who have gone through difficult times can support those presently experiencing the same difficulties, and nowhere is this more apparent than in complicated pregnancies.

Recognising this, Mitch Besser from the University of Cape Town’s Department of Obstetrics and Gynaecology started a project whereby mothers who had successfully coped with an HIV-positive pregnancy volunteered to mentor women who were diagnosed HIV-positive in their current pregnancy. He employed these ‘mentor mothers’ to provide counselling, education, personal support and encouragement for the other women, thus starting the ‘mothers 2 mothers’ (m2m) programme in antenatal clinics.

From modest beginnings 10 years ago the project has taken off beyond all expectations, not only in the Cape region of South Africa where the incidence of HIV-positive mothers is a ‘relatively low’ 15% but to other regions throughout the country where HIV-positive rates are over 30% and the organisation now has over 500 sites in seven countries (McColl BMJ 2012;344:e1590).

The m2m project was launched during times of low morale, when HIV-positive people were stigmatised, ostracised and victimised, when the government was in denial about the pathology of HIV/AIDS and antiretrovirals were scarce and the prevention of mother-to-child transmission was crude.

But the project has survived and grown dramatically, giving support to underprivileged women and their families in their thousands. It is an initiative of which Besser, the University of Cape Town and South Africa can feel rightfully proud.

Do we think of diabetics or epileptics or smokers or obese people who could form local support groups? Do we think of asking them to form virtual groups? Do we encourage patients to band together using the social media?

Do we really think outside the existing structures? The m2m project should inspire us.

Repeat caesarean section or vaginal birth after caesarean section?

  1. Top of page
  2. HIV success story
  3. Repeat caesarean section or vaginal birth after caesarean section?
  4. Emergency contraception
  5. Bandwagoning health
  6. Colorectal cancer
  7. Cervical cancer
  8. Testicles
  9. Screening or prevention?

Once a woman has had a caesarean section for a non-recurrent indication, she has the choice of a repeat caesarean section or a vaginal birth in future. In her decision she has to weigh the risks to her and her fetus of each mode of delivery but clear data are difficult to come by, and so the trial from Australia by a respected group led by Crowther et al. is welcome information (PLoS Med 2012;9:e1001192).

The prospective research included over 2000 women facing a delivery choice and most had made up their minds, with about half opting for an elective caesarean section and half for an attempted vaginal delivery. A handful were in equipoise and were randomised to one or other group. As one would expect in modern developed country circumstances the outcomes of both groups were excellent but there were differences in perinatal results.

The risk of perinatal death or serious morbidity was 1% in the elective caesarean section group and 2.5% in the group attempting vaginal birth. About half trying for vaginal delivery were successful. Another finding was that the women electing to try the vaginal route had a greater risk of scar rupture and significant haemorrhage. The absolute risks are small but potentially serious. The data are there on which women, their partners and their doctors can base their decisions.

Emergency contraception

  1. Top of page
  2. HIV success story
  3. Repeat caesarean section or vaginal birth after caesarean section?
  4. Emergency contraception
  5. Bandwagoning health
  6. Colorectal cancer
  7. Cervical cancer
  8. Testicles
  9. Screening or prevention?

Emergency contraception is probably the most underused asset in the family planning portfolio. It is accepted that it is not ideal for use on a regular basis but given the number of conceptions occurring unintentionally, why is it not more popular? There are 400 000 teenage births in the USA each year, never mind the number of pregnancy terminations. Only half of these young women were using any form of contraception with 80% using ‘low-effect’ methods so the need for widespread emergency methods is clear (JAMA 2012;307:1244–6). It may be a marketing or promotional or availability issue but it should be advertised as effective, cheap and obtainable. Perhaps its profile and acceptability need raising? It was encouraging to see the BMJ promoting its cause with a therapeutics piece by Prabakar and Webb (BMJ 2012;344:e1492).

The modern methods are:

  • • 
    levonorgestrel—a progestogen 1.5 mg as a start dose.
  • • 
    ulipristal acetate—a synthetic progesterone receptor modulator 30 mg immediately.
  • • 
    a copper intrauterine contraceptive device—probably the most effective.

The Yuzpe method, using combined estrogen and progesterone pills, is more likely to cause adverse effects and should only be used when alternatives are not available.

The succinct and clear article should be a standard handout at every family planning clinic and maybe there should be similar material in chemists, retail outlets and hairdressers. What about dispensing machines in pubs?

Hopefully society will look back on our present coyness with a smile in a few years time. Prevention remains better than curettage.

Bandwagoning health

  1. Top of page
  2. HIV success story
  3. Repeat caesarean section or vaginal birth after caesarean section?
  4. Emergency contraception
  5. Bandwagoning health
  6. Colorectal cancer
  7. Cervical cancer
  8. Testicles
  9. Screening or prevention?

We all appreciate that our health is our biggest asset. Staying healthy can be assisted by a healthy diet, weight control, exercise, stress management and avoiding bad habits. But can we improve the statistical odds of maintaining our wellbeing by supplements and screening?

Supplements in the form of extra vitamins and trace elements are of no value if we eat a balanced diet, and may be counterproductive. This of course does not stop millions of perfectly well people (doctors included) popping pills in fancy packaging or bright coloured sachets.

The field of taking medication prophylactically is a much more challenging environment. Aspirin is enjoying a wave of enthusiasm for preventing cardiovascular disease and cancers, especially colorectal and breast after 5 years of treatment (Rothwell et al. Lancet 2012;379:1602–12) and cholesterol-lowering statins seem to offer benefits. Add in antihypertensive agents, which statistically reduce cardiac events, and you are close to endorsing the Polypill, which will no doubt entice many into ‘statistical utopia’.

These preventive measures are worthy of debate but screening is more subtle. It is highly questionable whether screening healthy, low-risk individuals using prostate-specific antigen or mammography does more good than harm. Certainly the latest data show that prostate-specific antigen has a small effect on death rates from prostate cancer but no significant effect on all-cause mortality (Miller NEJM 2012;366:1047–8) but the potential harms of over-diagnosis are significant so its use is highly dubious for individuals. There are a host of other screening tests that are enjoying wide publicity at present and each of these deserves separate scrutiny.

Colorectal cancer

  1. Top of page
  2. HIV success story
  3. Repeat caesarean section or vaginal birth after caesarean section?
  4. Emergency contraception
  5. Bandwagoning health
  6. Colorectal cancer
  7. Cervical cancer
  8. Testicles
  9. Screening or prevention?

Screening for colorectal cancer is sensible because it is the second commonest cancer in women and the third most common in men worldwide. The lifetime risk is about one in 20 and 90% of people with colorectal cancer present over the age of 50 years.

Screening should start at 50 years and the choices are occult faecal blood tests annually, sigmoidoscopy every 5 years and colonoscopy every 10 years (Qaseem et al. Ann Int Med 2012;156:378–86). Faecal testing and sigmoidoscopy have the advantages of being less invasive and have been shown to reduce mortality in randomised trials but require more frequent surveillance and colonoscopy has the attractive possibility of only a few screenings in a lifetime with long-term reassurance available if no polyps are found (Bretthauer and Kalager NEJM 2012;366:759–60) The method of choice depends on benefits and harms, cost and availability but the prospect of screening for colorectal cancer should be raised in everyone over the age of 50 years.

Cervical cancer

  1. Top of page
  2. HIV success story
  3. Repeat caesarean section or vaginal birth after caesarean section?
  4. Emergency contraception
  5. Bandwagoning health
  6. Colorectal cancer
  7. Cervical cancer
  8. Testicles
  9. Screening or prevention?

The guidelines for cervical cancer screening have changed as our understanding of the natural history of the disease has matured. Knowledge that recurrent infections with oncogenic strains of human papillomavirus (HPV) cause the cancer has been crucial, as is the evidence that most women clear HPV infections readily and rapidly, obviating the necessity to test for HPV routinely and certainly not screening for its presence below the age of 30 years. In the USA the recommendations have changed significantly in the last few years.

First, the age of starting testing has been set at 20 years and is likely to move up to the mid-20s in keeping with the rest of the world. Second, the traditional annual ‘Pap & pelvic’ has been changed to a 3-yearly cytology test as of March 2012 according to the US Preventative Services Task Force (http://www.uspreventativeservicestaskforce.org). They also suggest 5-yearly screening if cytology is combined with HPV DNA testing in women older than 30 years. Finally, they suggest stopping screening at age 65 years if previous testing has been negative.

Whether HPV testing will be more cost-effective in women over the age of 30 years is the subject of debate (de Kok et al. BMJ 2012;344:e670). It is more sensitive in detecting clinically relevant lesions but less specific than cytology so other factors such as cost and prevalence come into play as well as future self-sampling for HPV, which is an attractive option. Costs are put at €65 for HPV testing but less than half that for Papanicolaou smear cytology in Europe.

Cervical screening has been one of the success stories of the last century and gains need to be consolidated with vaccine prevention programmes and ongoing vigilance but gynaecologists and all those involved in screening must know the latest recommendations.

Data continue to accumulate as to the effectiveness of treatment that follows smear-detected cancers compared with symptom-detected cancers with the latest work from Sweden showing a better prognosis following screening (Andrae et al. BMJ 2012;344:e900). Time will tell which tests, at what frequency and in which populations, will achieve the best results.

Testicles

  1. Top of page
  2. HIV success story
  3. Repeat caesarean section or vaginal birth after caesarean section?
  4. Emergency contraception
  5. Bandwagoning health
  6. Colorectal cancer
  7. Cervical cancer
  8. Testicles
  9. Screening or prevention?

There is a campaign in the UK promoting testicular awareness. Most men are aware that they have testicles and are rather attached to them but should they examine them regularly? ‘Yes,’ say rugger players and celebrities in loud and deep voices ‘to pick up testicular cancer early’.

Really?

There is no evidence that self palpation leads to early detection of testicular cancer, which is a rare disease, and it is far more likely that normal variations (like a varicocele) will be encountered, anxiety provoked, consultations required and even investigations ordered to provide reassurance. It is a daft idea but it has caught on and gain-saying the trend is met with hostility (Hopcroft BMJ 2012;344:e2120). The chances of useful discovery from routine testicular examination are miniscule. There are far more important issues celebrities could promote—like stopping smoking (Delamothe BMJ 2012;344:e2029)—but gonad groping? Testicles.

Screening or prevention?

  1. Top of page
  2. HIV success story
  3. Repeat caesarean section or vaginal birth after caesarean section?
  4. Emergency contraception
  5. Bandwagoning health
  6. Colorectal cancer
  7. Cervical cancer
  8. Testicles
  9. Screening or prevention?

Rather than making the screening ‘net’ so fine that it cannot be dragged through the water, let us preach prevention. A balanced diet plus exercise is far more important than all the screening in the world and leads to positive mental and physical health—and longevity (McNaughton et al. J Nutr 2012;142:320–5).

Footnotes
  1. These snippets are extracts from a monthly service called the Journal Article Summary Service. It is a service that summarises all that is new in obstetrics and gynaecology over the preceding month. If you would like to know the details of how to subscribe, please email the editor Athol Kent at atholkent@mweb.co.za or visit the website http://www.jassonline.com.