BMJ  2004;328:1506 (19 June), doi:10.1136/bmj.328.7454.1506

Minerva

Apparently it's not the little things that cause problems. Heartburn is one of those symptoms that gets worse when people are under stress and, as shown by a study in Psychosomatic Medicine ( 2004;66: 426-34)[Abstract/Free Full Text], the severity of heartburn seems to be most responsive to a major life event sometime during the previous six months, not an accumulation of minor stressors or mood fluctuations. Possible mechanisms include the increased level and frequency of acid in the oesophagus and the inhibition of gastric emptying of acid.

There's a new culinary show on Canadian television—an eight part series cooked up by an orthopaedic surgeon, with each episode featuring a specialist surgeon preparing two gourmet meat dishes. It's called "Close to the Bone" and claims to provide a blend of cooking, surgery, and lessons in human anatomy. The otolaryngologist offers up pig snout and calf's tongue; the hand surgeon prepares stuffed pig's trotter; the urologist makes lamb's kidney and deep-fried bull's testicles ( CMAJ 2004;170: 1825[Free Full Text]).

Patients are often asked to stop taking aspirin a week or so before cardiac surgery because it's assumed that by doing so they will bleed less during the procedure. But is this necessary? A Japanese team reporting the results of their pilot study found that after stopping aspirin the inhibition of platelet aggregation fell quickly after just one day and had completely vanished after three days ( Journal of Thoracic and Cardiovascular Surgery 2004;127: 1814-5[Free Full Text]).

In our world of advancing technology, Minerva was amused to read that the good old-fashioned paper clip can be just as useful as a specially designed—and presumably much more expensive—neurological device. According to a carefully conducted study which assessed digital nerve function by two point discrimination with a set of calibrated paper clips and compared these measurements with an instrument known as a Disk-Criminator, the paper clips performed just as well ( Academic Emergency Medicine 2004;11: 710-4[Medline]).

When 21 scientific articles with reprint orders of over 10 000 were compared with 21 articles with smaller reprint orders, the high reprint articles were subsequently cited much more often. Within two years the mean number of citations for high reprint articles was 121, compared with a mean of 47 for the others, but a third of the high reprint papers were cited 25 times or fewer. Studies that received funding from the pharmaceutical industry—probably the purchaser of the largest number of reprints—were cited more frequently than those that received funding from other sources ( International Journal of Technology Assessment in Health Care 2003;4: 711-4).

Researchers studying baby rats found a statistically significant reduction in brain mass after the rats were deprived both acutely and chronically of REM (rapid eye movement) sleep. Histological staining techniques also confirmed that programmed cell death (apoptosis) had taken place after the rats had been deprived of REM sleep. The researchers say these findings confirm the idea that REM sleep has an active role in preventing apoptosis in the developing brain ( Medical Hypotheses 2004;62: 876-9[CrossRef][Medline]).

Waxing lyrical about the use of medical jargon beloved by doctors, a columnist writing in the latest edition of the NHS Magazine (June 2004: 30) says that patients too sometimes enjoy a good diagnosis: "`You've got a sore shoulder' is no use at all, but `you've got a suprascapular bursitis' gets you out of sex, work, and the washing up for at least a fortnight."

People who take herbal remedies may be at risk of drug interactions if they're also taking warfarin. A postal questionnaire of 2600 patients prescribed warfarin, with a 54% response rate, found that 8.8% of them were taking one or more of the specified herbal remedies thought to interact with warfarin, and 14.3% of the respondents reported taking other complementary or homoeopathic medicines. The vast majority (92.2%) had not discussed their use of herbal medicines with any conventional healthcare professional ( British Journal of General Practice 2004;54: 439-41).

Upward-facing dog and cat stretches are yoga positions that Minerva uses when she needs to de-stress and blow away the cobwebs. Interestingly, a randomised controlled trial of a six month yoga or exercise class in people with multiple sclerosis found that, compared with a waiting list control group, both yoga and exercise produced a significant improvement in the experience of fatigue—but did not improve cognitive function or mood ( Neurology 2004;62: 2058-64[Abstract/Free Full Text]).

The availability of over the counter statins may be good for the public but could cause a headache for pharmacists. A letter in the Pharmaceutical Journal (5 June 2004: 706) says the onus will be on the profession to make sure that customers have all the information they need. This includes customers understanding baseline risk, absolute and relative risk reduction, and the concept of numbers needed to treat. Only then will they be able to make an informed choice about whether to spend their money on a daily statin or a subscription to the local gym.

A 50 year old woman who lives on a sheep farm presented to the accident and emergency department with a history of an abscess that had rapidly appeared on her thumb. A week earlier, her general practitioner had performed an incision and drainage, but even with a course of antibiotics the abscess did not heal. The patient subsequently admitted that no pus had been extruded on attempted drainage. We made a clinical diagnosis of cutaneous orf, and the lesion healed without any complications within a fortnight, without further intervention or medication. Cutaneous orf is a self limiting viral skin infection caused predominantly by contact with cattle and sheep. Sriram Rajagopalan, senior house officer, Sathyan Gunaseelan, clinical observer, Caithness General Hospital, Wick

Arm position alters blood pressure readings considerably, with the dependent arm position likely to lead to an overdiagnosis of hypertension. The American Heart Association states that when the patient is seated, "placing the arm on a nearby table top, a little above waist level, will result in a satisfactory position." An audit published in the Internal Medicine Journal ( 2004;34: 290-1)[CrossRef][ISI][Medline] found that only 8% of 182 clinicians chose the horizontal arm position in sitting patients, and 4% in standing patients.

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