BMJ  2004;329:120 (10 July), doi:10.1136/bmj.329.7457.120

Minerva

Stents have come into routine use as part of coronary angioplasty so fast that little evaluation has been published. The latest innovation is the drug eluting stent, and a review from England ( European Heart Journal 2004;25: 902-14[Abstract/Free Full Text]) quotes a consensus panel in the United States as saying that "the rapid evolution of stent design, deployment approaches, and adjuvant therapy have led to changes in clinical practice that precede rigidly controlled supporting scientific data." The National Institute for Clinical Excellence has recommended the use of drug eluting stents for patients with small vessels or long lesions but—says the journal—the policy is based on small numbers and short term follow up. Why the hurry?

Restenosis of a stent inserted during coronary angioplasty is thought to be less likely if the plasma concentration of homocysteine is low, and some research has suggested that this can be achieved by treatment with folic acid and vitamins B-6 and B-12. A randomised controlled trial ( New England Journal of Medicine 2004;350: 2673-81[Abstract/Free Full Text]) has now refuted that approach. Restenosis was more severe in the treated group, and cardiologists are warned that they should not give folate to patients who have had a stent inserted.

Another condition that has attracted the attention of the technologists is massive pulmonary embolism, mortality from which has shown little change for years—despite apparent advances in prophylaxis and treatment ( Cardiology 2004;102: 11-5[CrossRef][ISI][Medline]).One innovation is catheter thrombectomy—an evolving technology with three variants: simple aspiration through a syringe, mechanical fragmentation followed by aspiration, and rheolytic thrombectomy using a double lumen tube through which saline is passed at high velocity. The saline carrier has perforations through which the thrombus is sucked by the Venturi effect.

The American Cancer Society believes in early, aggressive screening for detection of the common cancers. Its current advertisement in CA a Cancer Journal for Clinicians (May-June issue) asserts that nearly 90% of cases and deaths from colorectal cancer can be prevented. Individuals at average risk should join a screening programme from the age of 50. They can choose from yearly faecal occult blood testing or flexible sigmoidoscopy, or both, or colonoscopy every 10 years, or a double contrast barium enema every five years. Minerva hopes that here in Britain doctors would be unlikely to have their strategies decided by an advertisement.

More mammographies? Researchers at Harvard ( Cancer 2004;100: 2338-46[CrossRef][ISI][Medline]) used data from the 2000 national health interview study to calculate the Gail score, a validated model of a woman's risk of developing breast cancer within five years, using information such as age, age at menarche, age at first birth, history of biopsy, breast cancer in relatives. Of 6410 women evaluated, 15.7% were at increased risk but had had no recent screening by clinical assessment or mammography. The conclusion? More effort by health professionals to persuade women at high risk to do something about it.

Exercise induced purpura occurs on the lower legs of people who have taken unusual exertion in hot weather, such as doing a marathon or walking in the mountains ( Dermatology 2004;208: 293-6[CrossRef][ISI][Medline]). The lesions may be erythematous, urticarial, or purpuric plaques, typically sparing the skin that is compressed by socks or shoes. The condition is rarely reported and appears in few textbooks, possibly because its victims (who are mostly women) are likely to recover spontaneously before they come within reach of a doctor. The cause is thought to be an acute failure of the calf muscle pump.

Telecounselling—communication by phone between a counsellor and a caller—is a major industry in Australia, with 131 non-profit organisations and an unknown number of commercial setups doing similar work ( Medical Journal of Australia 2004;180: 604-5[ISI][Medline]). Two of the larger providers answer about 850 000 calls a year. Most calls cover mental health or problems such as sexual assault, domestic violence, or cancer. The service providers see themselves as supporting vulnerable people rather than offering crisis intervention. These counsellors had not been formally evaluated.

The number of new cases of tuberculosis identified in Israel rose rapidly as massive numbers of immigrants arrived from Ethiopia and the former Soviet Union. Some were non-compliant, and their management made use of a law introduced by the British when they were responsible for the mandate over Palestine ( Public Health 2004;118; 323-8[CrossRef][ISI][Medline]). This gave courts the power to isolate people with infections for which they refused treatment. Between 1994 and 2001 a total of 3056 immigrants were found to have tuberculosis and 13 were brought before the courts and isolated. More recently, greater emphasis has been given to persuading patients to accept treatment.

This reusable cover for a cigarette pack is, depressingly, sold as "the new and innovative response to the larger health warnings that are now mandatory on all cigarettes sold across the EEC." A BMJ editor cites a friend who uses one of these covers in the hope that, if her mother glimpses it in her bag, she won't be caught out as a smoker. Trish Groves, senior assistant editor, BMJ, London WC1H 9JR

Women who have sex with women may believe that they need not worry about sexually transmitted infections. The risks may be small, but they should not be ignored. Investigation of 708 women attending lesbian sexual health clinics showed that trichomonas, genital warts, and genital herpes could be transmitted from woman to woman ( Sexually Transmitted Infections 2004;80: 244-6[Abstract/Free Full Text]). By contrast, gonorrhoea, chlamydia, and pelvic inflammatory disease could be acquired only through sex with men.

By no means all smokers develop lung disease—in fact only one in five eventually develops significant outflow limitation. Recent research has shown that progression to lung disease is associated with an increased inflammatory response to smoke ( Chest 2004;125: 1706-13[Abstract/Free Full Text].) A commentary in the same issue (pp 1599-1600) reacts to the news with hostility, warning that tests might be developed to identify people who might be genetically protected against smoke and so might believe they could become light smokers without doing themselves any harm. The reality is that smoke causes plenty of problems other than chest disease, and doctors have plenty of evidence to support their continued war against tobacco.

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