BMJ  2004;328:1446 (12 June), doi:10.1136/bmj.328.7453.1446

Minerva

A word of warning about drinking directly from cans of drink without washing them first. Madagascar's La Gazette de la Grande Ile (6 April 2004) reports the tale of a woman who had taken a boat trip with friends and drunk from a can of drink she'd put into the boat's refrigerator. She was taken ill and died two days later. The postmortem revealed she had died of fulminating leptospirosis, and examination of the can confirmed it had been contaminated with rat urine, which had dried on the top.

Losing your teeth can be a sign of heart disease or cerebrovascular disease. One link between the two phenomena may be high blood pressure. When two age matched groups of postmenopausal women were compared—67 with loss of teeth, 31 without—those with no missing teeth had significantly lower diastolic blood pressure and a tendency for lower systolic pressure. The researchers found no other significant associations with other traditional risk factors for vascular diseases ( Hypertension 2004;43: 1297-300[Abstract/Free Full Text]).

When it comes to the HIV-AIDS pandemic, we have a dilemma. Wealthy countries are giving generously with one hand but taking away with the other. An article in the Washington Post (24 May) says that African doctors and nurses are leaving public sector jobs in droves to take up more lucrative positions in foreign funded HIV-AIDS programmes. The result: public hospitals and clinics are being stripped of staff, and rural and slum outposts are being abandoned.

Euthanasia is one of those subjects that completely divides opinion. Writing in the International Journal of Palliative Nursing ( 2004;10: 214-5)[Medline], a psychologist says, "Those who have diametrically polarised opinions invariably base these on their life values, which are generally intractable. To achieve consensus on the issue of euthanasia is thus impossible." Given the complexity of the issue, she argues, it may be that the only justice is one of individual freedom. And if we choose as a society to manage that freedom, we should demand the most rigorous of scrutiny to ensure that justice, not expediency, is the driving motivation.

Another debate revolves around what's best for acute rupture of the Achilles tendon. Some say surgical intervention is the only way to restore normal tension and length to the tendon, while others advocate immobilisation in a plaster cast. A study that combined conservative management and removable orthotics in 140 consecutive patients reports better overall results than studies of operative repairs. The complication rate was 8%, with eight re-ruptures, two cases of deep vein thrombosis, and one temporary drop foot ( Journal of Bone and Joint Surgery 2004;86A; 1198-202).

Being traumatised in childhood can result in either a major depressive episode or post-traumatic stress disorder (PTSD). In girls, if the trauma occurs before the age of 13, the risk of developing depression is about the same as the risk of developing PTSD. After the age of 13, the risk of PTSD is much greater. But in almost a third of cases of PTSD, major depression is also present ( British Journal of Psychiatry 2004;184: 482-7[Abstract/Free Full Text]).

Does constipation and painful defaecation lead to children refusing to use a toilet, or is it the other way around? An analysis of data from 380 children taking part in a prospective longitudinal study of toilet training revealed that the first episode of constipation usually occurs before toilet refusal. The fact that hard bowel movements frequently occur before the onset of toilet refusal suggests that constipation is a chronic problem for many children which is not treated effectively ( Pediatrics 2004;113: e520-2[Abstract/Free Full Text]).

People who have strokes are also at a higher risk of developing dementia, compared with age and sex matched controls. Data from a cohort from the Framingham study show that sustaining a stroke doubles the risk of dementia (from 11% to 19.3%); adjustment for education and exposure to individual stroke risk factors didn't reduce the risk. Primary and secondary prevention of stroke should reduce the risk of all types of dementia considerably ( Stroke 2004;35: 1264-9[Abstract/Free Full Text]).

Train drivers who experience a "person under the train" accident are understandably shaken by such events. But most of their symptoms (anxiety, insomnia, and somatic conditions) in the immediate aftermath disappear within a year, and the vast majority of drivers have no short, medium, or long term impairment of their fitness to continue driving trains. Those most vulnerable were unaccompanied drivers who had been left to drive their train away alone immediately after the accident ( Occupational and Environmental Medicine 2004;61: 488-94[Abstract/Free Full Text]).

A randomised, placebo controlled, 12 week trial of 3 mg and 9 mg of budesonide (a locally acting steroid with minimal systemic exposure) and 7.5 mg of prednisolone (conventional steroid treatment) in rheumatoid arthritis reports that the symptomatic benefits reported with both the higher dose budesonide and prednisolone were achieved within two weeks of initiating treatment. The benefits lasted three months, and no rebound effect was seen after stopping treatment ( Annals of the Rheumatic Diseases 2004;63: 688-95[Abstract/Free Full Text]).

A 37 year old man presented with a large tender epigastric swelling after blunt abdominal trauma with a metal bar. Ultrasonography showed a rectus sheath haematoma. Three days later he began vomiting and hiccupping. His pain worsened. Computed tomography showed a large anterior abdominal wall hernia containing distended bowel loops. Surgery confirmed herniation through a 3 cm defect in the linea alba, which was repaired. He made an uneventful postoperative recovery. Blunt trauma is a rare cause of hernia formation. In light of an unexpected clinical deterioration in any trauma patient, it is important to review your initial diagnosis and consider further investigations. Frances Goulder, senior house officer, Stewart Walsh, specialist registrar, Neil Keeling, consultant, Eamon Coveney, consultant department of general surgery, West Suffolk Hospital, Bury St Edmunds, Suffolk IP33 2QZ

Like rabbits caught in the headlights, disaster victims often die, despite reasonable opportunities for escape, because they "freeze" in the face of danger. A study in Aviation, Space, and Environmental Medicine ( 2004;75: 539-42)[Medline] concludes that this behaviour happens because people can't keep up with processing cognitive information in a rapidly unfolding real-time environment. Because they are at different stages of neurological and cognitive development, children under threat behave differently from adults.

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Rapid Responses:

Read all Rapid Responses

Leptospirosis on cans: urban legend?

Paul N. Levett
bmj.com, 11 Jun 2004 [Full text]

High blood pressure and teeth: a fascinating relation!

Dr.Nasem A. Qureshi MD, IMAPA, LMIPS
bmj.com, 13 Jun 2004 [Full text]

Childhood trauma: psychiatric consequences!

Dr.Naseem A. Qureshi MD, IMAPA, LMIPS
bmj.com, 14 Jun 2004 [Full text]

Leptospira on drink can - Minerva as gullible?

P.A. Geis
bmj.com, 17 Jun 2004 [Full text]

Leptosporosis

Alison S Johnson
bmj.com, 30 Jun 2004 [Full text]