This is Journal Watch Direct, a twice-weekly
survey of new medical research, produced by the
Massachusetts Medical Society, publishers
of The New England Journal of Medicine,
Health News, AIDS Clinical Care and Clinical
Care for Prostatic Diseases.
  Twice a week, our physician-editors summarize
clinical research from a group of about 50
journals. We post the top two summaries,
along with the complete table of contents,
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  Contents copyright 1996, Mass. Medical Society.

Journal Watch Summaries for Friday, December 13, 1996.

MIXED NEWS ON GROWTH HORMONE.
  Ann Intern Med 1996 Dec 1; 125:865-72.
  Ann Intern Med 1996 Dec 1; 125:873-82.
  Ann Intern Med 1996 Dec 1; 125:883-90.
  Ann Intern Med 1996 Dec 1; 125:932-4.

HIGH RATES OF C. TRACHOMATIS INFECTION IN {*filter*}
PARTNERSHIPS.
  JAMA 1996 Dec 4; 276:1737-42.

SUICIDE IN PATIENTS WITH HIV.
  JAMA 1996 Dec 4; 276:1743-6.

DELAYING NURSING HOME PLACEMENT FOR PATIENTS WITH
ALZHEIMER'S.
  JAMA 1996 Dec 4; 276:1725-31.

PHYSICIAN-ASSISTED DEATH IN THE NETHERLANDS.
  N Engl J Med 1996 Nov 28; 335:1699-705.
  N Engl J Med 1996 Nov 28; 335:1706-11.

REASONS FOR RESISTANCE TO ORGAN DONATION.
  Arch Intern Med 1996 Nov 25; 156:2419-24.

C-SECTIONS FOR BIG BABIES?.
  JAMA 1996 Nov 13; 276:1480-6.
DT.-961213.

AN.-1.
HL.-MIXED NEWS ON GROWTH HORMONE.
NS.-Small short-term studies have shown that growth
hormone increases lean body and muscle mass in patients with
renal failure, burns, or malnutrition; {*filter*}s with
childhood-onset growth hormone deficiency; and athletes.
Three studies of recombinant human growth hormone (rhGH) and
an editorial from the December 1 Annals of Internal
Medicine indicate that questions about its safety and
efficacy remain unanswered.
   The first trial randomized 60 patients with AIDS and
wasting to 1.4 mg rhGH daily, 5 mg recombinant human
insulin-like growth factor 1 (rhIGF-1) twice daily, both, or
placebo. rhGH alone and in combination with rhIGF-1 produced
modest but significant weight gain (about 2 kg) at six
weeks, but it was not sustained through 12 weeks. rhIGF-1
alone was not associated with significant weight gain.
Increases in lean body mass were sustained through 12 weeks
in the combination therapy group only. Changes in
immunologic function, muscle function, and quality of life
were not significant in any group.
   The second trial randomized 178 HIV-infected patients
with unintentional weight loss to rhGH (0.1 mg/kg/day or
about 6 mg/day) or placebo. After 12 weeks, growth hormone
increased weight (mean increase, 1.6 kg), lean body mass
(mean increase, 3.0 kg), and treadmill work output compared
with little or no change in the placebo group. There were no
differences between groups in quality of life, days of
disability, or resource use.
   The last trial randomized 32 men with {*filter*}-onset growth
hormone deficiency to low-dose rhGH (initial average dose,
0.6 mg/day titrated to normalize insulin-like growth factor
1 levels) or placebo for 18 months. rhGH increased lean body
mass by 2.5 kg, reduced body fat, stimulated bone turnover,
and increased bone mineral density by as much as 5.1
percent. There was no effect on exercise capacity.      
   Comment: Despite initial enthusiasm about growth hormone,
it appears at best to have inconsistent and modest benefits
in patients with AIDS-associated wasting. Although there is
mounting evidence that dose-adjusted rhGH improves metabolic
outcomes in some growth-hormone deficient {*filter*}s, it remains
unclear whether any of these benefits are clinically
worthwhile, sustainable, or cost-effective. --CD Mulrow.
AU.-Waters D; et al.
TI.-Recombinant human growth hormone, insulin-like growth
factor 1, and combination therapy in AIDS-associated
wasting.
SO.-Ann Intern Med 1996 Dec 1; 125:865-72.
AU.-Schambelan M; et al.
TI.-Recombinant human growth hormone in patients with
HIV-associated wasting.
SO.-Ann Intern Med 1996 Dec 1; 125:873-82.
AU.-Baum HBA; et al.
TI.-Effects of physiologic growth hormone therapy on bone
density and body composition in patients with {*filter*}-onset
growth hormone deficiency.
SO.-Ann Intern Med 1996 Dec 1; 125:883-90.
AU.-Mantzoros CS; et al.
TI.-Whither recombinant human growth hormone?.
SO.-Ann Intern Med 1996 Dec 1; 125:932-4.

AN.-2.
HL.-HIGH RATES OF C. TRACHOMATIS INFECTION IN {*filter*}
PARTNERSHIPS.
NS.-What is the risk of infection for {*filter*} partners of
patients with Chlamydia trachomatis? This study compared
in vitro culture and DNA sequencing techniques for evaluating
infection among 494 {*filter*} couples attending {*filter*}ly
transmitted disease clinics.
   The patients were generally young and more than 90
percent were African American. C. trachomatis was diagnosed
by culture in at least one partner in 17 percent of the
couples, including 8.5 percent of males and 12.9 percent of
females. In couples with infected females, 42 percent of
males were also culture-positive; in couples with infected
males, 57 percent of females were positive.
   When PCR technology was used, higher rates of infection
were found -- 14 percent in males and 16 percent in females
-- and the difference between the sexes was no longer
significant. With PCR, the female-male and male-female
transmission rates were both about 70 percent. Many of the
subjects who were positive by either culture or PCR were
asymptomatic.
   Comment: These data demonstrate the high rate of
infection among {*filter*} partners, and that PCR is superior to
culture for detecting infection; they also emphasize the
importance of routine screening and treatment for partners
of infected patients. --TH Lee.
AU.-Quinn TC; et al.
TI.-Epidemiologic and microbiologic correlates of Chlamydia
trachomatis infection in {*filter*} partnerships.
SO.-JAMA 1996 Dec 4; 276:1737-42.

AN.-3.
HL.-SUICIDE IN PATIENTS WITH HIV.
NS.-How many people would commit suicide if they found out
they had HIV? Fortunately, not many HIV-positive patients
actually do so, according to the results of this prospective
cohort study of 4147 military applicants found to be
HIV-positive during screening for military service from 1985
to 1993. The National Death Index, which captures death
certificate data for the entire U.S., was used to identify
suicides in this cohort and in 12,437 HIV-negative controls
who were disqualified from service for other medical
conditions.
   Over a median 70-month follow-up, only 10 HIV-positive
subjects were found to have committed suicide -- a rate not
significantly higher than that of HIV-negative subjects.
Based on 1989 age-, race-, and sex-specific national
mortality rates, one would have expected 4.8 deaths from
suicide among the population of HIV-positive applicants. The
time from screening until death was less than 3 months for 3
of the 10 HIV-positive subjects.
   Comment: HIV-positive patients do not appear to be at
increased risk for suicide in this population. Among those
who do commit suicide, the risk may be highest in the first
months after screening. --TH Lee.
AU.-Dannenberg AL; et al.
TI.-Suicide and HIV infection: Mortality follow-up of 4147
HIV-seropositive military service applicants.
SO.-JAMA 1996 Dec 4; 276:1743-6.

AN.-4.
HL.-DELAYING NURSING HOME PLACEMENT FOR PATIENTS WITH
ALZHEIMER'S.
NS.-Helping families keep patients with Alzheimer's
disease at home often seems a hopeless challenge. This
randomized trial suggests that real gains can be made by
providing family caregivers with support and counseling.
   Researchers randomized 206 spouses of patients with
Alzheimer's disease to control or intervention groups.
Caregivers in the intervention group had individual and
family counseling sessions aimed at promoting communication
among family members, teaching techniques for problem
solving, and managing troublesome patient behavior. After
four months of counseling, the caregivers joined support
groups that met weekly; counselors were available for crisis
management at any time.
   The median time from enrollment to nursing-home placement
was 329 days longer in the intervention group than in
controls, and the overall rate of placement was 35 percent
lower with the intervention; this rate was reduced 82
percent in patients with mild dementia, and 62 percent in
those with moderate dementia.
   Comment: Rigorous evaluation of multidisciplinary
interventions for the chronically ill are all too rare. This
important study proves that optimal care for patients with
Alzheimer's disease requires treatment for the entire
family. --TH Lee.
AU.-Mittelman MS; et al.
TI.-A family intervention to delay nursing home placement
of patients with Alzheimer disease: A randomized controlled
trial.
SO.-JAMA 1996 Dec 4; 276:1725-31.

AN.-5.
HL.-PHYSICIAN-ASSISTED DEATH IN THE NETHERLANDS.
NS.-In 1990, the Dutch government sponsored a landmark
study on euthanasia and assisted suicide. That study has now
been repeated, using data from confidential interviews with
405 physicians and questionnaires completed by nearly 5000
physicians who attended deaths in late 1995.
   Between 1990 and 1995, the incidence of euthanasia
(performed at the patient's request) increased slightly,
from about 1.8 to 2.4 percent of all deaths. The incidences
of assisted suicide (about 0.3 percent) and administration
of {*filter*} to end life without the patient's explicit request
(about 0.7 percent) were similar in 1990 and 1995. In
addition, 20 percent of deaths in 1995 (vs. 18 percent in
1990) involved decisions to withhold or withdraw treatment.
   The situation in the Netherlands seems odd: Physician-
assisted death remains technically illegal, but since 1990
physicians have been asked to disclose all assisted deaths
to the coroner to ensure compliance with standards endorsed
by the government and the medical profession. A second study
that evaluated this notification procedure found that,
between 1990 and 1995, the percentage of reported cases of
assisted suicide rose from 18 to 41 percent. Not
surprisingly, reported cases were much more likely to have
satisfied criteria such as obtaining a second opinion, or
having a written request from the patient. Only 13 of 6324
reported cases have been prosecuted.
   Comment: Some will find the Dutch experience reassuring,
since the incidence of physician-assisted death does not
seem to have changed much, and an oversight mechanism is
gradually taking shape. But others will worry about a
"slippery slope" to less careful end-of-life
decision-making. --AS Brett.
AU.-van der Maas PJ; et al.
TI.-Euthanasia, physician-assisted suicide, and other
medical practices involving the end of life in the
Netherlands, 1990-1995.
SO.-N Engl J Med 1996 Nov 28; 335:1699-705.
AU.-van der Wal G; et al.
TI.-Evaluation of the notification procedure for
physician-assisted death in the Netherlands.
SO.-N Engl J Med 1996 Nov 28; 335:1706-11.

AN.-6.
HL.-REASONS FOR RESISTANCE TO ORGAN DONATION.
NS.-Over 16,000 patients have died while awaiting organ
transplantation during the past eight years. But, despite an
intense national educational campaign, donation levels have
been relatively flat for the past five years. To clarify
reasons for resistance to organ donation, this study
examined the results of focus groups conducted in five
cities.
   A total of 102 people aged 18-64 participated. One group
in each city consisted of people committed to organ donation
and one group consisted of those opposed to it. Opposed
groups in two cities were exclusively African-American.
   Both groups shared similar beliefs about organ donation
including a lack of understanding of the donation and
transplantation process and a mistrust of government
involvement. Those against organ donation thought organ
allocation was unfair (particularly racially and
economically biased) and transplantations were generally
unsuccessful and caused pain and suffering. They also
expressed concern that life support might be terminated
prematurely and a desire to "go to the grave whole." Many in
both groups thought that preferred status (i.e., the
preferential allocation of organs to families whose members
donate organs) would possibly encourage donation.
   Comment: Physicians who support organ donation should
encourage patients and families to consider it, refer
potential donors or their families to transplant counselors,
and educate their colleagues about the benefits of organ
donation. --TL Schwenk.
AU.-Peters TG; et al.
TI.-Organ donors and nondonors.
SO.-Arch Intern Med 1996 Nov 25; 156:2419-24.

AN.-7.
HL.-C-SECTIONS FOR BIG BABIES?.
NS.-Fetal macrosomia -- generally defined as a birth
weight of more than 4000 grams -- increases the risk for
infant shoulder dystocia at delivery, which can lead to
permanent injury of the brachial plexus. Consequently,
ultrasonography has been recommended to predict macrosomia
and identify candidates for cesarean section. To analyze the
effectiveness and cost of this strategy, this decision
analysis compared three policies: management without
ultrasound; management with ultrasound with c-sections
performed at estimated fetal weights of 4000 g or more; and
management with ultrasound with a cutoff for cesarean
delivery at 4500 g.
   Using the 4000-g cutoff in nondiabetic women, an
estimated 2345 cesarean sections would need to be performed
at a cost of $4.9 million to prevent a single case of
permanent brachial plexus injury. At 4500 grams, 3695
c-sections and $8.7 million would be needed for each injury
prevented. The results were more favorable among diabetic
women (489 c-sections and $880,000 with the 4000-g policy,
versus 443 and $930,000 with the 4500-g policy).
   Comment: The authors conclude that elective c-section for
ultrasonographically diagnosed macrosomia is an untenable
policy for nondiabetics, but worthy of consideration for
diabetic mothers, whose infants tend toward macrosomia and
are often born with the shoulders of linebackers.
--RH Pantell.
AU.-Rouse DJ; et al.
TI.-The effectiveness and costs of elective cesarean
delivery for fetal macrosomia diagnosed by ultrasound.
SO.-JAMA 1996 Nov 13; 276:1480-6.