NEJM 21 Jun 2007 Vol 356

Dracunculiasis is a most ornamental word, but the little dragon to which it refers – the guinea worm – is a horrible parasite which, thanks to a lot of humble effort in remote communities, is on the verge of extinction.

No longer will you be able to tease your squeamish loved ones with pictures of long white worms being pulled out of people’s extremities.

But most of the world is still plagued with insect-borne diseases – including plague itself, of course, but more commonly malaria, dengue fever, Lyme disease and so on, plus leishmaniasis. This perspective piece looks at the various strategies by which we can attempt either to kill the insect hosts or the organisms they carry. In the case of leishmaniasis, of which the visceral form can be fatal, an Indian trial of intramuscular paromomycin has proved highly successful. As man is the only reservoir, this may eventually lead to the elimination of the organism.

Know anything about smouldering multiple myeloma? Ah, you guessed – it’s pre-myeloma which has been picked up by detecting a high level of monoclonal IgG or IgA protein, or a bone marrow showing more than 10% plasma cells. The Mayo clinic has looked at all patients detected from 1970, and plotted their risk of developing overt disease. If you are one of the 75% who haven’t got full MM by 15 years, your risk diminishes thereafter.

One surrogate end-point that’s become popular in the last few years is coronary artery calcification. Lower that and you have to lower cardiovascular risk, surely. This study proves that oestrogen therapy lowers coronary calcification by quite a dramatic amount. Other studies show that it increases cardiovascular risk. So yah-boo to surrogate markers. Always go for hard end-points: merely chalky ones won’t do.