BMJ  2004;328:58 (3 January), doi:10.1136/bmj.328.7430.58

Minerva

Breast cancer is found largely in older women; women aged over 65 account for 13% of the female population but for two thirds of all deaths from breast cancer ( Annals of Internal Medicine 2003;139: 835-42[Abstract/Free Full Text]). Few studies have looked closely at these figures, but the available evidence shows that screening using mammography every two years would reduce the death rate at an acceptable cost.

Heart failure is common in elderly people, but clinicians may find it difficult to recognise ( Age and Ageing 2003;32: 565-9). A test that has an "emerging role" in diagnosis is measurement of the B type of natriureteric peptide (BNP). Concentrations of BNP are raised in heart failure and correlate with left ventricular systolic dysfunction. A bedside test is available; a normal value virtually excludes heart failure.

A review in the New England Journal of Medicine ( 2003;349: 2136-46)[Free Full Text] of the treatment of irritable bowel syndrome urges a multicomponent approach based on the type (diarrhoea, constipation, pain) and severity of the symptoms. It warns that current pharmacological treatments are likely to be ineffective when ongoing psychosocial problems remain undiscovered or untreated.

A study in Leeds of 627 patients who had had 711 liver transplants found that 26% had developed neurological complications after their operations ( Neurology 2003;61: 1174-8[Abstract/Free Full Text]). The most frequent complications were diffuse encephalopathies and seizures; these were more numerous in patients whose initial liver disease had been alcoholic liver damage or primary biliary cirrhosis. Forty six of these patients had died.

A new use has been found for lidocaine cream (Emla). Some patterns of self injury may be reinforced by the sensory stimulation, rather than social or psychological stimuli. A report in Developmental Medicine and Child Neurology ( 2003;45: 769-71)[CrossRef][ISI][Medline] describes a child with autism who slapped his cheek at a rate of 45 slaps a minute. When the cheek was numbed with Emla the rate of slapping fell to 20 a minute, blocking the sensory response.

Doctors treating patients for erectile dysfunction seem not to be interested in assessing the state of their arteries—yet there is good evidence that problems with erection are a good marker for cardiovascular disease ( British Journal of Urology International 2003;92: 875-9). Lifestyle changes that should be recommended to all patients with erectile dysfunction are stopping smoking, losing weight, and taking exercise—not very surprising, but likely to be effective.

Also in the British Journal of Urology International ( 2003;92: 886-9) is a review of the treatments available for the management of incontinence after prostatectomy. The conclusion is that the highest rates of patient satisfaction came when patients had been treated with an artificial urinary sphincter—endorsed as long ago as 1999 at the International Consultation on Incontinence. Cost seems to be the problem.

An electronic stethoscope linked to a computer can generate a spectral analysis of heart murmurs, and research in the United States ( Chest 2003;124: 1638-44[Abstract/Free Full Text]) has shown that murmurs generated at > 300 Hz correlate well with the transvalvular gradient across the aortic valve. The technique is said to be a simple and inexpensive means of assessing the severity of aortic valve stenosis.

Is fatal choking sometimes associated with antipsychotic drugs? A review of the data on 70 patients who died from choking found that compared with the general population they were 20 times more likely to have been treated for schizophrenia. The risk for those receiving thioridazine was 92 times greater ( British Journal of Psychiatry 2003;183: 446-50[Abstract/Free Full Text]). Nevertheless the risk was numerically small: 591 patients would have to be treated with thioridazine for seven years for a single death to occur.

Obstructive sleep apnoea has effects on several hormones ( Journal of Internal Medicine 2003;254: 447-54[CrossRef][ISI][Medline]). These include falls in the concentrations of sex hormone binding protein and total testosterone, free T4, aldosterone, and insulin growth factor. All these changes can be reversed by effective treatment using continuous positive pressure ventilation. As the severity of the sleep apnoea is reduced the amounts of the hormones return towards normal and are accompanied, patients say, by an increase in the quality of life.

A study in Boston of adult cyclists who needed hospital treatment for road accidents found that the numbers seen rose by 30% between 1994 and 1999 ( Injury 2003;34: 825-9[CrossRef][ISI][Medline]). Thirty five of the 222 people studied had raised blood alcohol concentrations and half those with closed head injuries had not been wearing helmets. The lessons, say the authors, are obvious: what is less clear is how to get people to modify their behaviour.

A 75 year old man presented with a sudden onset toothpaste-like cheesy discharge from a cystic lump on the volar aspect of his right ring finger. He gave no history of recent trauma. He had had a small asymptomatic lump for 20 years. No organisms grew on culture and the lump was completely excised. The most commonly considered diagnoses are ganglion, implantation dermoid, cyst, abscess, lipoma, subcutaneous foreign body granuloma, and tendon sheath xanthoma. Histology shown an ancient schwannoma (peripheral nerve sheath tumour) with central cystic degeneration. Because of its cystic consistency, a finger schwannoma may be mistaken for a ganglion or inclusion cyst. Himanshu Sharma, specialist registrar, B J Singh, consultant, department of trauma and orthopaedics, Monklands Hospital, Airdrie, Lanarkshire ML6 0JS

In developed countries the standard treatment for peptic ulceration is based on eradication of Helicobacter pylori. This approach is of little use in developing countries, in which the prevalence of infection with H pylori may be as high as 70-90%. A study in Peru ( Journal of Infectious Diseases 2003;188: 1263-79[CrossRef][ISI][Medline]) found that treatment seemed to eradicate the infection, but within 18 months 30% of patients had become reinfected.

"Watchful waiting" was promoted as one answer for men found to have symptomless raised concentrations of prostate specific antigen (PSA). A meeting of the American Urological Association has now been told that as many as half the men who started on watchful waiting have chosen to have active treatment. "Men just can't stand watching their PSA gradually rise," the meeting was told; either the patient or the doctor loses his nerve. Yet the pioneer study in Sweden still supports "wait and see," and watchful waiting doesn't lead to impotence or incontinence.

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