BMJ  2004;329:E317 (14 August), doi:10.1136/bmj.329.7462.E317

BMJ USA: Minerva

Minerva

Despite repeated beatings about the head, 82 amateur boxers participating in multiple bouts during a seven day tournament showed no evidence of cognitive dysfunction immediately afterwards. Their serial performance in tests of simple reaction times, choice reaction times, and working memory tests after three bouts was equal to that of boxers who had taken part in one and two bouts, and that of non-boxing control participants. Boxers whose bouts had been stopped by the referee proved the exception ( Neurology 2004;62: 1497-1502[Abstract/Free Full Text]).

Smoking can cause chronic obstructive pulmonary disease, but only 15-20% of smokers get it. A study in Chest ( 2004;125: 1706-1713)[Abstract/Free Full Text] shows that bronchial cells from smokers who have obstructive disease produce a greater inflammatory response to stimulation with an irritant (tumor necrosis factor alpha) than smokers without airflow limitation. This suggests that some smokers respond much less to irritants in cigarettes.

Groundwater contamination by arsenic has doubled the lifetime risk of death from liver, bladder, and lung cancers in Bangladesh. Millions of hand pumped wells installed since the 1970s were supposed to protect 95% of the population from pathogenborne disease, but over the years almost half the population has been chronically exposed to arsenic ( American Journal of Public Health 2004;94: 741-744[Abstract/Free Full Text]).

Sticking to a gluten-free diet can be pretty difficult and is possibly harder for children. Conventionally such diets have eliminated wheat, rye, barley, and oats. A randomized controlled study of giving oats to children with newly diagnosed celiac disease shows that oats can be safely eaten in moderation without preventing clinical or small bowel mucosal healing ( Gut 2004;53: 649-654[Abstract/Free Full Text]).

The prevalence of fatigue in primary care patients ranges from 10% to 40% depending on the definition used. A prospective study of US medical students reported in the Journal of Hypertension ( 2004;22: 691-695)[CrossRef][ISI][Medline] found that low blood pressure may be a risk factor for the later development of idiopathic chronic fatigue, especially in women. Hypotension was defined in this study as having a systolic blood pressure of under 110 mm Hg in men and under 100 mm Hg in women. Follow up took place at five or 10 years after graduation.

Minerva has often thought it would be safer and less fraught for patients with infections to be treated at home, rather than be admitted to hospital. In a randomized trial of home versus hospital administered intravenous antibiotics in adults, the former seemed to be well tolerated and was not associated with any major disadvantage to quality of life or clinical outcome. Home treatment cost about half that of hospital care ( Journal of Infection 2004;48: 263-268[CrossRef][ISI][Medline]).

Should doctors wear white coats? Most patients, especially older ones, would apparently rather see doctors wear white coats as a way of identifying who they are. Most doctors, on the other hand, perceive them as an infection risk and find them uncomfortable ( Postgraduate Medical Journal 2004;80: 284-286[Abstract/Free Full Text]). Minerva wonders if the infection risk would seem as great if coats were exchanged for clean ones every day.

Injecting knees with intra-articular saline after arthroscopy seems to produce good pain relief. Not only that, but a randomized double blind study showed that injecting 1 mL of saline was just as effective as injecting 10 mL ( Anesthesia and Analgesia 2004;98: 1546-1551[Abstract/Free Full Text]). The authors suggest the finding of such a major placebo effect may have implications for the interpretation of previously published placebo controlled studies of intra-articular analgesia.

To date, the only drug with any prophylactic efficacy for chronic tension headaches is amitriptyline, which offers a success rate of about 30% reduction in headaches. Another, newer, antidepressant that is better tolerated can now be added to the armamentarium. In a small randomized, double blind, placebo controlled crossover trial mirtazapine produced better results in terms of duration and intensity and was well tolerated ( Neurology 2004;62: 1706-1711[Abstract/Free Full Text]).

It's bad news for men. A study from California concludes that some of the same risk factors for heart disease also predict erectile dysfunction. Taking a prospective view of community based men aged 30-69 and following them up 25 years later revealed that age, body mass index, and blood cholesterol and triglyceride concentrations were each significantly associated with an increased risk of erectile dysfunction. Smoking was marginally more common in those with severe dysfunction ( Journal of the American College of Cardiology 2004;43: 1405-1411[Abstract/Free Full Text]).

View larger version (108K): [in this window] [in a new window]   Vitiligo is well known to occur at the site of minor trauma, the so called Koebner phenomenon. This 69 year old woman has severe chronic obstructive pulmonary disease with repeated hospital admissions for exacerbations. Treatment included oxygen and nebulized therapy via a facemask. This vitiligo was noted on her hospital admission. There is no evidence of vitiligo elsewhere nor of any other autoimmune disease. Ali Mohammed senior house officer Martin Whitehead specialist registrar Evelyn Miller consultant respiratory unit Southern General Hospital, Glasgow, G51 4TF, UK

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 immobilization 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; 1198-1202).

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Vitiligo Etiology

Jerome Z Litt
bmj.com, 18 Aug 2004 [Full text]