BMJ  2004;328:1084 (1 May), doi:10.1136/bmj.328.7447.1084

Minerva

Wouldn't it be nice to find an efficacious alternative to discectomy? Sadly, a prospective randomised trial of epidural injection of a steroid versus full blown surgery in people with a symptomatic herniated lumbar disc found that the injection wasn't as effective as surgery in reducing symptoms or disability. Epidurals did, however, have a role: nearly half the patients who received one, having had no relief from non-invasive care, reported relief from pain for up to three years ( Journal of Bone and Joint Surgery 2004;86-A: 670-9[Abstract/Free Full Text]).

"Observational blindness" can lead to a missed diagnosis. In an effort to overcome this, a medical educator at Yale University School of Medicine teamed up with the Yale Center for British Art to help medical students learn about art appreciation. After just two hours studying a classical painting and discussing what they saw, the students' diagnostic skills improved. Compared with a group of students who sat through an additional anatomy lecture, those who had attended the fine art class were better able to pick out clues in photos of patients (www.nature.com/nsu/010913/010913-11.html).

Obesity has an effect on the onset of functional impairment in elderly people independent of general health and health related behaviours such as drinking and smoking ( Gerontologist 2004;44: 206-16[Abstract/Free Full Text]). Being overweight also predicts functional impairment over time. But less easy to untangle from this study is the relation between obesity and health behaviours, making it difficult to determine which one precedes the other.

Hospital trusts in the United Kingdom have installed around 17 500 television sets that can't be turned off beside patients' beds. Apart from the glare and the flickering, which have been driving some patients to distraction, they've also been causing distress to patients who simply want a break from constant stimulation. The latest phase of the installation will include terminals that offer email and internet services. These have an off switch (http://news.bbc.co.uk 8 April 2004).

A small double blind randomised controlled study of the use of cannabis extract for treating tremor in patients with multiple sclerosis has found that it is no more effective than placebo. Around 60% of people with multiple sclerosis have tremor, and the study was powered to detect a 50% improvement in the tremor index. The group receiving cannabis extract tended to experience more subjective relief from their tremors ( Neurology 2004;62: 1105-9[Abstract/Free Full Text]).

A tale of two sisters in the Journal of Clinical Pathology ( 2004;57: 439-41)[Abstract/Free Full Text] illustrates the point that not all genetic abnormalities cause the disease with which they are associated. The sisters, who lived in similar environments, were found to be homozygous for the mutated gene C282Y, which causes haemochromatosis, and they both had abnormal liver function tests. After liver biopsies, one sister was diagnosed as having haemochromatosis and the other as having non-alcoholic steatohepatitis.

After road collisions, the most common cause of accidental death in Turkey is falling off the flat roof of a building, often a cheap two storey house with no guard rail. Falls are most common in the summer, when people sleep outside on their roofs to keep cool. Half those injured were younger than 10. Of the 643 people injured by falling, 96 died ( Injury 2004;35: 425-8[Medline]).

There's a stunning tenfold disparity in mortality, in Toronto, Canada, in women aged 18-44 between those who are homeless and those who are housed ( CMAJ 2004;170: 1251-2[Free Full Text]). It's described as a smouldering public health crisis by the president of a healthcare programme for homeless people in Boston, who paints a dramatic picture of people dying in the very shadows created by towering healthcare institutions—a picture that won't change, he says, until housing and health care become fundamental rights for every human being.

Another public health picture involving towers is described in Chest ( 2004;125: 1248-55)[Abstract/Free Full Text]. A cross sectional study in a sample of 96 rescue and recovery ironworkers at the World Trade Center disaster site between 11 September 2001 and 8 February 2002 reports that 77% had symptoms, and the prevalence was similar in smokers and nonsmokers. Cough was most prevalent, although objective evidence of lung disease was less common. Any longer term sequelae remain to be seen.

Current feeding guidelines recommend delaying the introduction of solids in order to protect children from developing asthma and allergy. But a study in Archives of Disease in Childhood ( 2004;89: 309-14)[Abstract/Free Full Text] refutes this advice. More than 600 children were followed up to the age of 5.5 years. Not only was no protection offered by late introduction of solids against wheezing, atopy, or eczema, but when eggs were introduced late, the risk of eczema was significantly greater.

Phlegmasia caerulea dolens is a rare manifestation of severe deep vein thrombosis and is associated with malignancy. Progression to venous gangrene can occur if treatment is not initiated promptly; mortality and morbidity are high. This patient developed the condition four days after starting to take anticoagulant drugs. Subsequent investigations confirmed bilateral thrombosis of iliac veins, extending along the inferior vena cava up to the renal veins, and also an associated bronchogenic carcinoma. Kiran K Peddi, specialist registrar, G P Butcher, consultant physician, department of gastroenterology and medicine, Arrowe Park Hospital, Upton, Wirral CH49 5PE

Are patients as interested in reading their own medical records as we might think? Over a third are very interested, and it seems that a consumer approach to healthcare is a better predictor of interest than are clinical characteristics. Factors such as finding the internet very important for health information and subscribing to a health newsletter were more closely related to interest than were health status, use of health care, education, or income. Most of those who wanted access to their notes said they wanted to find out what their doctor had said about them ( Archives of Internal Medicine 2004;164: 793-800[Abstract/Free Full Text]).

Credible information on pet and human health issues can be found at www.pethealthcouncil.co.uk. The very useful address list includes everything from organisations concerned about the counselling needs of pets (and their owners) to those that promote pets as therapy. There's also a treatise on choosing the right pet if you have an allergy.

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Rapid Responses:

Read all Rapid Responses

Television sets that can't be turned off

Robert McMaster
bmj.com, 1 May 2004 [Full text]

The Bible has the answer

Melvyn H Brooks
bmj.com, 24 May 2004 [Full text]