BMJ No 7122 Volume 315
Minerva Saturday 13 December 1997
| These keloid scars in the right ear developed in a woman aged 26 just two weeks after she had had both ears pierced. The left ear did not develop any keloid scarring. The lesions showed no signs of spontaneous regression after 12 months, when they were treated successfully by surgery followed by radiotherapy. Keloid formation is commoner in racial groups with dark skins and is notoriously difficult to treat as the recurrence rate is high.
Judith Hanif,
Sebastian Thomas, Adam Frosh, Submissions for this page should include the signed consent to publication from the patient | |
| ||
Women with the factor V Leiden mutation (which increases the
risk of thromboembolic disease) are best identified by the careful
taking of a family history rather than by population screening, says a
review in Annals of Internal Medicine
(1997;127:895-902). Those women in whom the mutation is confirmed
should not use combined oral contraceptives and may require
anticoagulation during pregnancy and the puerperium.
Further data on the continuing controversy about the safety of
vaginal delivery in breech presentation have come from Sweden. A study
looked at intrapartum and early neonatal mortality in 6542 singleton
fetuses presenting by the breech (British Journal of Obstetrics
and Gynaecology 1997;104:1288-91). There were two deaths among
the 2248 babies delivered vaginally and two deaths also among the 4029
delivered by caesarean section (not a significant difference), but more
of the babies delivered vaginally had low Apgar scores at five minutes.
The mortality in both groups was substantially lower than that in many
other series.
Genetic tests on 86 women who either had developed breast cancer
before the age of 40 or had a family history of breast cancer or
ovarian cancer before the age of 50 found that only nine had either of
the two mutations known to be linked with breast cancer, BRCA 1 or 2
(Journal of Medical Genetics 1997;34:990-5). Geneticists
continue to believe that other mutations will be found to explain the
development of cancers of the breast and ovary in comparatively young
women.
Neurosurgery still has a place in the treatment of patients with
mental disorders who are desperately ill, says a review in the
Journal of Neurology, Neurosurgery, and Psychiatry
(1997;63:701-5). The verdict of pioneers that "every patient probably
loses something by this operation, some spontaneity, some sparkle, some
flavour of the personality" probably remains true, but surgery has an
established place for obsessive-compulsive disorder and depression.
Minerva had expected that the WHO would want coverage of the
forthcoming election for its director general. But when she phoned to
check the names and backgrounds of the seven candidates she was told
that the press office had been instructed "neither to help nor to
hinder" journalists who wanted information. After a game of 20
questions to which all replies were yes or no she was left wondering
why an organisation that is funded by its member states is so
arrogantly secretive.
Laparoscopic appendicectomy has not yet gained unequivocal
acceptance by general surgeons, says a review in the Annals of
the Royal College of Surgeons of England (1997;79:393-402).
Nevertheless the diagnostic information given by the laparoscopy is of
clear benefit to two groups of patients in whom the diagnosis may be in
doubt: young women who may have gynaecological disorders and obese
patients in whom thorough inspection of the abdominal cavity is not
possible through a small laparotomy incision.
Sixty years ago the American surgeon J B Costen described
a syndrome of pain, tinnitus, and impaired hearing associated with
dysfunction of the temporomandibular joint; he thought the underlying
cause was dental malocclusion (Annals of Otology, Rhinology, and
Laryngology 1997;106:820-2). Nowadays the fault in the
temporomandibular joint is thought more often to be due simply to
osteoarthritis, and the syndrome is included within the spectrum of
myofascial pain. In keeping with current thinking, the underlying
causes now cited are psychological stress and anxiety.
The fact that alcoholic liver disease becomes more likely the
more people drink is unsurprising, but two large studies in Denmark and
Italy have expanded the data on risk (Gut
1997;41;857-8). In the Danish study 7% of people having more than 70
drinks a week had cirrhosis and 19% had alcoholic liver disease. In
Italy 4% of people drinking more than 42 units a week had cirrhosis
and 10% had liver disease. The advice given in the journal is for
people to drink within sensible limits, stick to one kind of drink, and
consume drinks at or around mealtimes.
Some recent publications in the South African
Medical Journal (1997;87:583-4, 1396-7) have focused attention
on the "puzzle of African obesity." Around 8% of black men in
South Africa but 45% of women are obese, yet in the women the obesity
does not seem to have harmful effects on their blood pressure or their
serum lipid concentrations. The fat is mostly "safe," distributed
on the thighs and buttocks and not around the waist, but that is only
part of the explanation, which includes low resting energy
expenditure and sex hormones.
A study in Canada suggests that women taking hormone replacement
treatment have breasts which are denser on mammographic screening than
those of women not taking the hormones (Surgery
1997;122:669-74). Dense breasts reduce the diagnostic value of
mammographic screening - one of the reasons it is not much use in young
women - so the finding is, in the word of the authors, "worrisome."
Minerva has never been an enthusiastic believer in the health
benefits of taking vitamin C, so she approached with caution a report
in JAMA (1997;278:1682-6) of its potential as a
protection against atheroma. Tests on volunteers aged 24-54 showed that
a high fat meal reduced endothelial function for up to four hours
through the accumulation of triglyceride rich lipoproteins.
Pretreatment with vitamins C and E blocked this effect of fat on the
endothelium. That is a long way from preventing heart attacks.
Further data linking smoking by the parents and the health of
their children has come from the Oxford survey of childhood cancers
(British Journal of Cancer 1997;76:1525-31). The report
attributed 14% of cancers in childhood to smoking by the father.
Maternal smoking had virtually no effect, suggesting that the link is
due to an action of smoking before conception
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