BMJ No 7124 Volume 316
Minerva Saturday 3 January 1998
| After a mastectomy women should be offered the whole
range of reconstructive options. One of these is the transfer of skin
and muscle from the abdominal wall to the chest with microvascular
techniques. Patients should be warned that with this method the
sensation of the reconstructed breast will not be normal. This woman
aged 58 burnt her reconstructed breast on a hot water bottle. Otherwise
she was delighted by the success of the procedure.
Alastair J
Platt,
specialist registrar in plastic surgery,
| |
| Submissions for this page should include the signed consent to publication from the patient | ||
Americans continue to dispute the value of mammography in women
aged 40-49. An analysis in Annals of Internal Medicine
(1997;127:955-65) has concluded that "screening is relatively cost
ineffective in women aged 40-49.... To prevent one death clinicians
would need to screen 2500 women, whereas routine screening of only 270
women aged 50-69 would also prevent one death."
Hereditary haemochromatosis is a disorder of iron metabolism
that affects 1 in 300 people of Northern European descent: the carrier
rate is about 10%, and a simple genetic test will identify 90% of the
homozygotes (Gut 1997;41:841-4). The disease may be
fatal if not treated, but if treatment is started early in life the
life expectancy is normal. A chill note in the report warns that before
genetic testing is introduced "ethical issues need to be addressed
such as how insurance companies will view homozygous people with no
signs of iron overload."
Minerva is a long term fan of the British Kidney Patient
Association, which since 1975 has raised funds to improve the quality
of lives of patients who have developed renal failure. Its appeal
includes an article by Sir Cyril Chantler recalling that when he
started recommending transplants for children he was worried about the
length of time the grafts would survive. Ten year patient survival
rates now average 88% for children over the age of 5, and many of the
pioneer patients have children of their own (BKPA, Bordon, Hampshire
GU35 9JZ).
A study in Australia of the sexual behaviour of homosexual men
found that those who were HIV positive were more likely than the others
to have unprotected anal sex (AIDS Care 1997;9:637-49).
The explanation is that the HIV positive men sought out positive
partners for unprotected sex - but as the report points out, apart from
a risk of reinfection with different strains of HIV and other
infection, there is a possibility of (re)infection with drug resistant
strains of HIV.
Doctors and members of the public who argue that patients
with alcoholic liver disease should be given lower priority for liver
transplantation than those with more "deserving" diseases have no
medical evidence on which to base their prejudice (British
Journal of Psychiatry 1997;171:497-500). The short and long
term outcomes for patients with alcoholic liver disease are similar to
those for patients with other liver diseases, even when the small
proportion who return to misusing alcohol is taken into account.
As a student Minerva was taught to give digoxin to all
patients in heart failure. Later she learnt that it was useful only in
patients with atrial fibrillation. But the results of studies
reviewed in the European Heart Journal
(1997;18:1685-8) have shown that patients in sinus rhythm do benefit
from digoxin and that the benefit continues for years. Angiotensin
converting enzyme inhibitors and digoxin remain the treatments of
proved value for most patients with severe heart failure.
Patients with pain in the chest who have a raised ST
segment in their electrocardiogram have clearly sustained an infarct;
but what about those without this sign? A study of 773 patients seen in
an emergency room in Hamburg (New England Journal of Medicine
1997;337:1648-53) found that measurement of the serum
concentrations of troponin I and T distinguished between patients with
myocardial damage and those without in 99% of cases. The report
concludes that a negative result of this test allows rapid, safe
discharge of patients who have come to hospital complaining of chest
pain.
The picture paragraph showing the telephone bill of a woman with
dementia (1997;315:1478) omitted the name of one of the authors, Dr E
Davies, senior house officer in psychiatry. This was an oversight by
Minerva, who offers her apologies.
Two thirds of doctors and nurses working in an accident and
emergency department in London were not in favour of relatives being
present in the resuscitation room (Journal of Accident and
Emergency Medicine 1997;14:366-9). The more experienced that
staff were, however, the more likely they were to agree that relatives
might benefit from being present, and the report concludes that
training for emergency room staff should include the management of
distressed relatives observing a resuscitation.
A survey by the audit unit of the Royal College of Obstetricians
and Gynaecologists of endometrial destruction procedures collected data
from 690 doctors who had treated 10,680 women (British Journal
of Obstetrics and Gynaecology 1997;104:1329-31). The main
finding was a complication rate of 4.45, showing that any form of
ablation or resection was safer than a hysterectomy. Ablation by laser
or roller ball proved safer than the procedure with a resectoscope.
Studies in sleep laboratories suggest that young adults should
sleep for 8-9 hours each night. A survey of 1,007 young Americans
(American Journal of Public Health 1997;87:1649-53)
found that they had been averaging fewer than seven hours and that many
were bothered by daytime sleepiness. Sleepiness was most prevalent in
single people who worked full time - who should, presumably, either
work less or play less.
Cirrhosis of the liver is perceived as a chronic disease, but
some data from Sweden (Addiction 1997;92:1523-36) showed
that a fall of 1 litre of alcohol per year in average consumption in
Stockholm was associated with a fall of 12% in mortality from
cirrhosis in the same year.
Pregnant women develop cholecystitis no more or less frequently
than those who are not pregnant, but they present greater problems. A
review in the British Journal of Surgery
(1997;84:1646-50) concludes that surgery should be avoided if possible
since cholecystectomy is associated with a high rate of fetal loss. In
fact, over 90% of patients do well when treated conservatively.
Laparoscopic surgery may have changed the picture: 60 cases have been
reported with no perinatal or maternal mortality, and the operation can
be done under epidural anaesthesia.
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