BMJ  2004;329:60 (3 July), doi:10.1136/bmj.329.7456.60

Minerva

The name pityriasis rosea was given to the exanthematous illness in 1860—a long time ago—but its exact cause remains uncertain. The clinical signs (herald patch and secondary eruption) and complete resolution within 8-12 weeks point to an infection, but at present all that can be said is that the role of the human herpes viruses 7 and 6 is controversial, while "not guilty" verdicts have been given to five or more other viruses and several bacteria. A review in Epidemiology and Infection (2004;132: 381-90)[CrossRef][Medline] concludes that the clinical picture is strong evidence for an infection, and that further investigation is needed to identify it.

Sixty per cent of deaths from breast cancer occur in women aged over 65, but until recently the treatment of women of this age was empirical, largely because elderly women were excluded from most clinical trials. Several randomised trials including older women have now reported ( British Journal of Surgery 2004;91: 655-6[CrossRef][ISI][Medline]). These have shown that tamoxifen alone is inadequate treatment (and so, probably, is treatment with aromatase inhibitors alone) and should be given only to very frail women with a life expectancy of less than a year. Local treatment is important not only to control local disease but also for improved survival.

Randomised clinical trials do not need to be blind. A pilot study for a randomised controlled trial of water birth versus other birth recruited 148 eligible women; 68 were excluded because they definitely wanted a water birth, and 20 others had a preference and decided not to be randomised. That left 60 who were randomised ( British Journal of Obstetrics and Gynaecology 2004;111: 537-45). Randomisation seemed not to affect the women's satisfaction with the birth. The findings of the investigations done on the babies were mostly not statistically significant, but the conclusion was that there is a good case for a much larger multicentre study.

More evidence of the value of statins: data from the Global Registry of Acute Coronary Events (GRACE) were used to study patients with acute coronary syndromes ( Annals of Internal Medicine 2004;140: 857-66[Abstract/Free Full Text]). Those who had been taking statins before the coronary event were found to have a less severe presentation than those who had not; they had fewer complications while in hospital and lower hospital death rates.

A questionnaire study of 1375 middle aged men and women in Sweden has found an association between nocturia and major depression as diagnosed by the major depression inventory ( British Journal of Urology International 2004;93: 1253-6). The questionnaire asked about mental and somatic health, sleep, sleepiness, and nocturia. Fifteen per cent of both men and women got up at night to pass urine. Major depression was associated with a sixfold increase in nocturnal voiding in men and a threefold increase in women.

More use should be made of racial and sociological data on the patterns of suicide throughout the world, says a brief letter in the American Journal of Public Health (2004;94: 908-9)[Free Full Text]. For example, African-Americans have a lower rate of suicide than the general population, and the age distribution of suicide also varies. In white Americans, suicide rates are higher in old age than in adolescence or early adulthood, whereas the opposite is the case in African-Americans. These data provoke many questions: why are elderly African-Americans protected from suicide? Are they less marginalised? Are elderly African-Americans more likely than white Americans to seek psychiatric help?

Morbidly obese patients who need elective surgery are nowadays often encouraged to attend an outpatient assessment clinic in which they are told about the hazards of surgery in patients who have a body mass index of 32 or greater. Experience in one such clinic ( Anaesthesia 2004;59: 570-3[CrossRef][ISI][Medline]) found that 52 of 102 patients given advice decided to postpone their operations while trying to lose substantial amounts of weight. Sadly, only 8 of the 52 managed to reduce their body mass index by 3 or more during the 18 months the clinic remained in business. The other patients had opted for regional anaesthesia or simply getting on with the surgery.

As politicians argue about various ways of reducing the time people spend on NHS waiting lists, surgeons are using health related quality of life instruments to identify the optimum timing of operations such as total hip and knee arthroplasties ( Journal of Bone and Joint Surgery 2004;86A: 963-74). Arthroplasty is usually most cost effective in patients with low preoperative disability scores, but many patients are still reluctant to consider major surgery for simple arthritis.

Ten per cent of the population of the United States was born outside the country, and visiting their friends and relatives accounts for a disproportionately high volume of international travel. A review in JAMA (2004;291: 2856-64)[Abstract/Free Full Text] asserts that people visiting their family's home are often prescribed inappropriate prophylaxis for disorders such as malaria. They are at additional increased risk because they stay away for a long time, visit high risk areas, and do not take the recommended drugs.

View larger version (101K): [in this window] [in a new window]   A 39 year old Afro-Caribbean man attended the emergency department with a four hour history of tongue swelling, with no obvious precipitating cause. He was hypertensive and had been treated with enalapril (an angiotensin converting enzyme inhibitor) for seven months. The tongue swelling subsided completely within 48 hours after enalapril was withdrawn. One of the most likely causes of angioedema is treatment with an angiotensin converting enzyme inhibitor. A high index of suspicion is needed as the condition is reversible by withdrawing the offending agent. Priya Gauthama, senior house officer, Laura Taylor, senior house officer, Mathew Patteril, specialist registrar, department of anaesthetics, Southmead Hospital, Bristol BS10 5NB, L E R Pope, senior house officer, ENT services, Southmead Hospital

Give doctors a clear health promoting health message and they will do their best to pass the story on—even at the cost of vexing colleagues by the repetition. Circulation (2004;109: 2705-12)[Abstract/Free Full Text] has just published yet another paper saying that eating fish one or more times a week reduces the risk of death from coronary heart disease. But they go on to warn that whether pure fish oil supplements have the same effect on coronary disease as whole fish remains questionable, and doctors should be cautious when recommending supplements.

Minerva sees some very aged joggers and outdoor exercise enthusiasts in London parks, so she was not surprised by some data from the United States on injuries in people aged 65 and over. In 2001 a total of 62 164 were seen in emergency departments for treatment for injuries acquired from sports or recreational activities ( Injury Prevention 2004;10: 134-8[Abstract/Free Full Text]). Most were due to five activities: cycling, doing exercises, fishing, golf, and snow skiing. Fishing? Injuries from hooks, sunburn, and insect bites.

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Dr.Naseem A Qureshi MD,IMAPA,LMIPS
bmj.com, 5 Jul 2004 [Full text]