BMJ  2004;329:240 (24 July), doi:10.1136/bmj.329.7459.240

Minerva

Explaining the difference between bacterial and viral infections is a persistent problem, but there's now evidence that the two might not be quite as separate as once thought. A clinical trial involving more than 37 000 children has shown that use of the pneumococcal vaccine prevented 31% of pneumonias associated with any of seven respiratory viruses—raising the possibility that infant pneumococcal immunisation might reduce morbidity and deaths linked to influenza and other viral pneumonias in children and adults ( Nature Medicine 2004; doi:10.1038/nm1077).

When the United States had a widespread energy blackout last August, many people with home medical devices got into a panic. A retrospective review of patients presenting to one emergency department with conditions related to medical device failure found that they accounted for almost a quarter of all patients admitted to the hospital during the interval of the study, and that those not admitted spent 15 hours on average in the department before going home ( Academic Emergency Medicine 2004;11: 786-9[CrossRef][Medline]).

While all that was going on across the Atlantic, Britain had an unusual heat wave. A two week study of the maximum temperatures recorded in a general practice's drug cupboards, and in drug bags placed in cars' luggage compartments during this time, found that the maximum temperatures recorded on each day far exceeded 25°C. In addition, a survey of local pharmacies found that none had air conditioning or kept a temperature log. Most drug licences specify storage at 25°C or less ( Journal of the Royal Society of Medicine 2004;97: 328-9[Abstract/Free Full Text]).

Minerva has often suspected that cough medicines bought over the counter are a bit of a waste of money, and a study in Pediatrics ( 2004;114: e85-90)[Abstract/Free Full Text] shows she might be right. The placebo controlled trial of 100 children with upper respiratory tract infections found that diphenhydramine and dextromethorphan—common ingredients in cough syrups—were no better than flavoured water at reducing nocturnal coughing and sleeping difficulties. One author says the results confirm that time and proper hydration are the best treatments.

The results of observational studies on fish consumption and the risk of stroke are confusing, but a meta-analysis of cohort studies points to a clear message: the intake of fish is inversely related to the risk of stroke, and ischaemic stroke in particular. Eating fish just three times a month may confer protection ( Stroke 2004;35: 1538-42[Abstract/Free Full Text]).

Some people with sleep disturbance turn to alcohol in an effort to self medicate their insomnia, and this may be more likely in people who lie awake worrying about things. A prospective survey found that, relative to people without sleep disturbance, people with poor sleep due to worry at the start of the study had double the risk of developing an alcohol related problem more than a decade later. The risk was highest for those with an underlying anxiety disorder ( American Journal of Psychiatry 2004;161: 1197-203[Abstract/Free Full Text]).

As fears about the spread of HIV grow in Asia, a phase 1 trial of a vaginal microbicide called Buffergel has found a high level of acceptability among HIV negative women in Malawi, Zimbabwe, India, and Thailand. Women from Africa were virtually unanimous in their desire for such a product, suggesting that an individual's perception of being at risk outweighs concerns about potential side effects and how to use the product ( American Journal of Public Health 2004;94: 1159-64[Abstract/Free Full Text]).

Waxing lyrical about the love-hate relationship that exists around the use of clinical guidelines, a writer in the Journal of Family Planning and Reproductive Health Care ( 2004;30: 150-1)[Medline] says gone are the days of GOBSATS (good old boys sitting around tables) for making decisions. Now we have systematically developed, evidence guided recommendations involving multidisciplinary input, including the patient/consumer perspective. Whether this more sophisticated process improves clinical outcome still depends on finding ways of getting people to actually use the damn things.

Some studies have shown an association between multiple sclerosis and exposure to stress and contact with pets, such as cats and dogs. One suggestion is that infection with Toxocara catis or T canis in previously unexposed people could, under conditions of long term stress, trigger the onset of multiple sclerosis. Testing the hypothesis would be relatively easy: existing samples of cerebrospinal fluid or preserved brain tissue that had been taken soon after the diagnosis was made could be examined for Toxocara antibodies ( Medical Hypotheses 2004;63: 59-61[CrossRef][ISI][Medline]).

A 30 year old woman presented to the emergency department with a two week history of an itchy rash. It had started on the umbilicus as a red papule one day after the delivery of her child, and within two days had spread to the arms, lower back, bottom, and legs. Clinical examination showed symmetrical multiple red papules and plaques mainly on the legs and forearms and intact blisters on the forearms and dorsum of hands. Biopsy confirmed gestational pemphigoid. Her skin improved rapidly with systemic steroids. One in 50 000 pregnant women is affected, and the risk to the fetus is small. The aetiology is suspected to be an autoimmune response to sex hormones. The average onset in first presentations is at 21 weeks' gestation, but up to a quarter of cases start in the first week after delivery. David Tighe, senior house officer, accident and emergency department, E Ladoyanni, specialist registrar, S W Lanigan, consultant, department of dermatology, Sandwell and West Birmingham Hospital, Birmingham B17 8Q

Erectile dysfunction has a strong and independent association with silent cardiac ischaemia in people with apparently uncomplicated type 2 diabetes ( Circulation 2004;110: 22-6[Abstract/Free Full Text]). The implications are twofold. Firstly, erectile dysfunction might become a useful marker to identify diabetic patients at risk of silent ischaemia. Secondly, it might be sensible to perform an exercise electrocardiogram before starting treatment for erectile dysfunction, especially in people with other cardiovascular risk factors.

Summer is doing its usual thing in Britain: it's July and it's pouring with rain. But cheer up; Christmas is only five months away. Minerva has been asked to remind readers to please send in any offerings for the Christmas BMJ by 30 September.

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