BMJ  2004;329:E323 (11 September), doi:10.1136/bmj.329.7466.E323

BMJ USA: Minerva

Minerva

Minerva

There's a new culinary show on Canadian television—an eight part series cooked up by an orthopedic 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 foot; 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: 1814-1815[Free Full Text]).

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: 290-291)[CrossRef][Web of Science][Medline] found that only 8% of 182 clinicians chose the horizontal arm position in sitting patients, and 4% in standing patients.

The leading cause of death in the armed forces and police forces in some African countries is AIDS. In Nigeria, for example, secrecy and multiple sex partnering in the Nigerian navy may be partly responsible for the HIV pandemic in that country. In a survey of 480 Nigerian naval personnel, about a third said they had had sex with a female sex worker and 41% had not used a condom at the last visit. Married men were four times less likely to use a condom than single men ( BMC Public Health 2004;4: 24[CrossRef][Medline]).

Another area where we've still got a long way to go is persuading men to visit their family doctor. The difference in life expectancy rates between men and women is partly attributable to the fact that early detection rates of serious disease among men are lagging. Public Health News (June 14, 2004: 14-16) says many men still don't want to be seen as anything but tough, and that's not an image consistent with admitting physical or emotional vulnerability. Low visit rates may also be a failure of health services to make themselves more attractive to men.

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: 381-390)[CrossRef][Medline] concludes that the clinical picture is strong evidence for an infection, and that further investigation is needed to identify it.

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: 902-919[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 randomized controlled trial ( New England Journal of Medicine 2004;350: 2673-2681[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.

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: 244-246[Abstract/Free Full Text]). By contrast, gonorrhea, chlamydia, and pelvic inflammatory disease could be acquired only through sex with men.

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, UK L E R Pope senior house officer ENT services, Southmead Hospital

By no means do 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: 1706-1713[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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Enalapril-associated angioedema

Anita Gewurz, et al.
bmj.com, 9 Oct 2004 [Full text]