BMJ  2004;328:356 (7 February), doi:10.1136/bmj.328.7435.356

Minerva

With the doom-mongers of hormone replacement therapy (HRT) claiming its early demise after more than 40 years of use, it'll be interesting to see what happens to the HRT market. In 2001, it was worth over £43.3bn and was still growing. Now that HRT isn't considered as safe as was first thought, pharmaceutical companies' revenues have been dropping. A report from visiongain (www.epharmaceuticalnews.com/) entitled "Is this the end of HRT?" says that although the risks to health are very small, the HRT market will continue to decline, but the extent will depend on how well the pharmaceutical industry communicates with women and doctors.

Being unable to stand upright, otherwise known as "orthostatic intolerance," is common after a general anaesthetic and is associated with an increased risk of postoperative morbidity. Is it related to the failure to maintain normal blood pressure, and to age and sex? A head-up tilt test conducted on 104 patients just after they had minor surgery under general anaesthetic found that the incidence of orthostatic hypotension was 76% among women over 40, 72% among men over 40, 46% among younger women, and 63% among younger men ( Anaesthetics and Analgesia 2004;98: 40-5[Abstract/Free Full Text]).

Neonatal jaundice, caused by an accumulation of bilirubin, is usually treated with phototherapy, but drug treatment might be the way of the future. A Chinese herbal remedy for jaundice (Yin Zhi Huang), which is taken in the form of a herbal tea, is now known to activate a liver receptor that enhances the clearance of bilirubin ( Journal of Clinical Investigation 2004;113: 23-5[CrossRef][ISI][Medline]).

A writer in the Journal of the Royal Society of Medicine ( 2004;97: 3-5)[Free Full Text] asks whether medical schools are paying for education or technical training. Medicine is unusual in that academics are involved with routine professional activity, including research, and the purpose of medical education is not merely to provide a workforce for the NHS. Different resources pump in money to fund different activities. The lines of accountability must be such, he says, that they support all the activities involved.

The Society of Medical Writers evolved and metamorphosed from the General Practitioner Writers' Association, which came into being about 20 years ago. The original meetings provided nothing less than "balm to the souls of those taking part, with not a mention of audit, or management or facilitation." Instead, there was a ferment of argument and discussion about books and writing, with medicine as the common ground, and its revelation of the human condition. The society's journal is called The Writer, and membership is now open to anyone who's interested, regardless of discipline (www.somw.org).

When we eat influences how much we eat. Researchers hypothesised that eating earlier in the day would result in a lower overall daily intake. Their findings, reported in the Journal of Nutrition ( 2004;134: 104-11)[Abstract/Free Full Text], suggest that eating in the morning fills people up more than other times, and can indeed result in an overall daily reduction. Late night snacking fails to fill people up and can lead to an overall increase in daily intake.

Attention-deficit hyperactivity disorder (ADHD) causes ripples of dissent wherever you go, and the debate about what exactly it is, how it's diagnosed, and how or whether to treat it continues. The British Journal of Psychiatry ( 2004;184: 8-9)[Free Full Text] asks whether ADHD is best understood as a cultural construct. Railing against this, a UK psychiatrist says broad social influences probably contribute to the recognition of the disorder, rather than to its presence.

Emergency departments have to schedule cover 24 hours a day, seven days a week. Different shifts are perceived to offer different levels of stress, both personally and professionally. A two year study of scheduling at one American teaching hospital found that despite scheduling changes designed to improve equality, no improvement in perceived stress could be identified. The authors say the next step is to identify other predictors of stress, fairness, and job satisfaction within emergency medicine faculties ( Academic Emergency Medicine 2004;11: 111-4[Medline]).

Inflammatory mechanisms have been implicated in the pathogenesis of Alzheimer's disease, possibly via the cyclo-oxygenase-2 enzyme. But a one year randomised, blinded controlled trial of a selective COX-2 inhibitor (rofecoxib) failed to show that it slowed the progression of the disease. Possibly the disease process is too advanced to modify in people with established dementia, but it may be that the role of COX-2 is simply not as important as has been thought ( Neurology 2004;62: 66-71[Abstract/Free Full Text]).

When there is doubt, in many medical disciplines the answer is often 10% or 90%. In respiratory medicine, the figure is more like 15%. For example, about 15% of smokers develop clinical signs and symptoms of chronic obstructive pulmonary disease. But why don't more develop the condition? It may be that there are as yet unidentified factors which are critical to developing it and which are held only by a subgroup of smokers. Genetic studies are looking promising ( Chest 2004;125: 3-5[Free Full Text]).

A 56 year old woman presented with a five year history of a steadily growing erythematous lesion on the right cheek. It had been treated as rosacea, with no sustainable effect. She had previously had several sunburns. Clinical examination showed a 2.5 cm square, intensely erythematous patch with non-distinct margins. No ulceration or associated lymphadenopathy was present. The biopsy showed an amelanotic lentigo maligna with no invasion. The patch was surgically removed, and on histology this specimen showed a focus of an invasive malignant melanoma in vertical growth phase. Amelanotic melanomas comprise 2% of all melanomas, and most commonly affect white women in their late 40s on sites that have been exposed to sun. The prognosis is unclear. E Ladoyanni, specialist registrar, A Abdullah, consultant, department of dermatology, G D Sterne, consultant plastic surgeon, SY Chan, consultant pathologist, Birmingham Skin Centre, City Hospital, Birmingham B17 7QH

Plus ça change... Fifty years ago, the 12th congress of the Women's International League for Peace and Freedom was held in Paris. The resolutions passed included one that ratified the Geneva Protocol on the prohibition of use of poison gas and bacterial warfare, and another that human rights should be granted to everyone, without discrimination on political or any other grounds. An end to racism, the right to read, and the end of foreign occupation also featured highly ( American Journal of Public Health 2004;94: 32-5[Free Full Text]).

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Bah humbug

Ivan L Marples
bmj.com, 6 Feb 2004 [Full text]