Amalgam amalgamation?

547

investigate all women who have had a seizure during pregnancy orin the first ten days postpartum, irrespective of whether eclampsia isthought to be the cause. Finally, there must be greater politicalawareness of the need to improve funding and staffing because ofthe potential shortage of personnel in the next decade or more."There is no room for complacency. Constant reminders to all thosein authority of the priority of all aspects of maternity care are vital,for the children of today are the parents of tomorrow."

1. Maternal Mortality: the way forward: some implications of the Report on ConfidentialEnquiries into Maternal Deaths in the United Kingdom 1985-87. London: RoyalCollege of Obstetricians and Gynaecologists. 1992. Pp 96. £7. ISBN 0-902331558.

Familial testicular cancer

If a man has a brother with testicular cancer, he stands a 9 timesincreased chance (compared with the general population) of havingthis disease by the time he is 50, according to the findings of thelatest study of familial testicular cancer. Even if, as Fonnan et allsay, this estimate is out by 100% the risk is greater than that of mostother cancers: a man who has a father with the disease will still have araised risk (4-fold). The UK researchers claim to have the largestseries of testicular cancer world wide, and are confident of theirfindings. Although they examined the possibility of linkage to themajor histocompatibility complex gene on chromosome 6, theycould not prove, on the basis of the powerful sib-pair analysis, thatthere is a major gene association in testicular cancer families.Nonetheless, much of their evidence points to strong genetic links.Age at diagnosis was significantly lower in familial than non-familialcases (29 vs 32-5 years) and there was a substantial difference in ageat onset between fathers and sons. This might indicate geneticanticipation, in which genetic conditions are more serious andappear earlier in successive generations. The presence of bilateraltumours was higher than expected (6% vs 2-5%), and other pairedorgans such as breast, eye, and kidney are more often affectedbilaterally in familial cases. Certain families with familial disease hada strikingly high prevalence of other urogenital abnormalities,undescended testes, and inguinal hernia, although no significantassociations with testicular cancer were seen. The next step is to

investigate linkage with loci on other chromosomes. First-degreerelatives of affected men might be well advised to practiceself-examination of the testes in the meantime.

1. Forman D, Oliver RTD, Brett AR, et al. Familial testicular cancer: a report of the UKfamily register, estimation of risk and an HLA Class 1 sib-pair analysis. Br J Cancer1992; 65: 255-62.

Simvastatin

Since its introduction in May, 1989, as a treatment for primaryhypercholesterolaemia, the UK Committee on Safety of Medicines(CSM) has received 738 reports via the "yellow-card" system ofadverse reactions to simvastatin (’Zocor’, MSD).l Abnormalhepatic function-typically raised serum alanine and aspartatetransaminase-accounted for 36 reports. Hepatic dysfunction wasusually mild and symptom-free, but there have been 5 reports ofreversible hepatitis and 2 of jaundice. There have also been 48reports of myalgia, 7 of increased serum creatine kinase

concentrations, 3 of myositis, and 10 of myopathy, and there hasbeen 1 report of severe myopathy in a patient who was takingsimvastatin and cyclosporin. The CSM believes that the 5 reportsthey have received of cataract with simvastatin a possibleside-effect suggested by studies in dogs-do not indicate a problemwith the drug. Other adverse reactions include 65 reports ofheadache, 44 of skin rash, 34 of diarrhoea, 20 of insomnia, 19 ofabdominal pain, 17 of dyspepsia, 12 of depression, and 11 ofarthralgia. The safety profile from spontaneous reports is similar tothat seen in clinical trials. The CSM warns that because thetherapeutic benefit of simvastatin can only be maintained bylong-term treatment, continued vigilance is important.

1. Anon. In focus: simvastatin. Current Problems; Feb 1992.

Cascade of change

The [14 billion UK annual community care budget needs moreprofessional and flexible management to enable sufficient resourcesto be channelled to users and carers, according to the latest report ofthe Audit Commission.1 Despite the principles of interagencycooperation defined in the Community Care Act, 1990, health andlocal authorities still have different priorities and often fail to drawup an agreed agenda for service provision. The difficulties ofimplementing effective management are compounded by thepatchwork nature of community services: health authority andsocial service boundaries are "hopelessly entangled," which

prevents both short-term and strategic planning initiatives frombeing successfully realised. Service providers are often slow torespond to local needs and coordination of primary and hospital carewith social services is frequently poor. The report recommends aclear distinction be drawn between "care managers"-those whomust plan care on behalf of users and carers-and the serviceproviders. Care managers can establish locally integratedcommunity care (LINCC) schemes to provide a seamless servicebetween providers. Implementation of the 1990 Act is only halfcompleted2 and considerable rationalisation and re-organisation ofhealth-service bureaucracy must take place if its aims are not to bethwarted.

1. Audit Commission. Community care: managing the cascade of change. London:HMSO, 1992. Pp 49. £8.50.

2. Editorial. Long-term care in the UK: do we need it, does it matter, who will pay?Lancet 1992; 339: 96-97.

Snakes alive!

Promiscuity is traditionally a male prerogative, but a study fromSweden suggests that females improve their chances of producinghealthy offspring if they indulge in multiple matings.l Femalemembers of a small community living in the grassy meadows ofsouthern Sweden, apparently oblivious of the attentions of fourvoyeuristic scientists, mated up to eight times in three weeks buttended to avoid copulating with the same male more than once.Stillbirths were common in this population (31%), but the mostpromiscuous females were the least at risk. Madsen et aP suggestthat, in multiple matings, competition between sperm within thefemale reproductive tract ensures that the genetically "better" malesbecome fathers and pass on their "good" genes to their offspring-and so, in theory, the more competitors the better. Females arenotoriously choosy, but their judgment may not always be sound.The female viper, for one, is apparently unable to spot the male mostlikely to give her live-born children. The stillbirth rate varied widelyamong females that had mated with only one male: three of sevenmales fathered 71 % livebom offspring, but two produced only deadinfants.

1. Madsen T, Shine R, Loman J, Hakansson T. Why do female adders copulate sofrequently? Nature 1992; 355: 440-41.

Amalgam amalgamation?We are, perhaps, what we eat. But what we eat with might get

overlooked. Enamel and dentine are all very well, from a crematorialpoint of view, but filling materials, particularly mercury-basedamalgams, are causing increasing concern to environmentalists;Germany has limited amalgam fillings to molars (see Lancet Feb 15,p 419). In Sweden alone, some 360 kg of mercury has been said to bereleased into the atmosphere by crematoria in 1988; duringcremation the jawbone is heated to 650°C, whereas mercury boils atabout 350°C. Extraction, although no doubt less painful than whenalive, is unlikely to be a popular solution. A researcher in Swedennow suggests an alternative, the ’Emcoplate’ ampoule.1 Theampoule is designed such that, when placed on the coffin beforecremation, it releases as vapour its selenium contents at the sametime that mercury is released from the fillings. 85% of the mercuryis likely to be transformed into mercury selenide; grey, harmlesscrystals that can be raked out with the ashes.

1. Anonymous. Science & Technology Newsletter. Stockholm: Swedish InternationalPress Bureau, September, 1991.