BMJ  2004;329:926 (16 October), doi:10.1136/bmj.329.7471.926

Minerva

High homocysteine concentrations are significantly associated with coronary artery disease, and they are mediated by genetic mutations. When people with genotypes associated with high homocysteine concentrations adopted a Mediterranean diet—which is high in retinoids, folic acid, and fibre and seems to help prevent coronary artery disease—their homocysteine concentrations were reduced ( American Journal of Clinical Nutrition 2004;80: 849-54[Abstract/Free Full Text]). This finding should interest policy makers.

The links between dietary salt and cardiovascular disease have puzzled environmental physicians for a long time. Arguments have been especially fierce in the Netherlands, where a further study has been conducted ( Journal of Internal Medicine 2004;256: 324-30[CrossRef][ISI][Medline]). This showed that the higher the intake of salt the greater the amount of albumin in the urine. Since albuminuria is a known risk factor for heart disease and hypertension, these findings help piece together the jigsaw. The relation seems to be true for children as well as adults.

When a child is admitted to hospital because of wheezing the explanation may be "a virus" or a worsening of an atopic illness. Better diagnostic tests are now allowing clinicians to make reliable diagnoses in these circumstances. A report in the Journal of Allergy and Clinical Immunology ( 2004;114: 239-47)[CrossRef][ISI][Medline] draws a distinction between babies under the age of 3, who are most likely to have a virus infection, and older children, who are likely to have atopic characteristics and in whom diagnostic tests for viruses give negative results in as many as 40% of admissions.

A warning appears in the Annals of Internal Medicine ( 2004;141: 264-71)[Abstract/Free Full Text] that physicians are "overperforming" surveillance colonoscopy in patients found to have hyperplastic polyps. Published guidelines say that repeat colonoscopy is not advised, but half of the gastroenterologists questioned recommended repeat colonoscopy every three years or more often. The report concludes that unjustified overuse of surveillance colonoscopy after polypectomy will deplete resources that could be better used elsewhere.

Ageing Minerva has colleagues who recall the early years of the NHS, when young Australian surgeons came to Britain to work in busy district hospitals to get cutting experience. Nowadays, surgeons from Oz gain their experience in the rural outback of Australia, and the Australian and New Zealand Journal of Surgery ( 2003;73: 95-7) approves of this trend; it is calling for six months of rural surgery to be made a requirement for trainees rather than an option.

As hurricanes continue to devastate the Caribbean, data are emerging on the preparations made by local health authorities to deal with natural disasters. One focus of interest is the trend towards more numerous and more intense heat waves in both Europe and North America ( American Journal of Public Health 2004;94: 1520-2[Abstract/Free Full Text]). A third of cities at risk had no written advice for doctors, and some of the advice was useless—one example being the use of hand held fans to relieve heat. Fans have been shown to have no useful cooling effect and, if used too enthusiastically, may aggravate heat stress.

Now that HIV/AIDS can be seen as a chronic illness, what help should be given to people with the illness who want to return to paid work? Studies in the United States and elsewhere ( AIDS Care 2004;16: 758-66) have shown that a substantial proportion of people are put off looking for a job because of fears that they may lose their disability benefits. Other factors include loss of publicly funded health insurance and fears of discrimination in the workplace. These obstacles will need attention if people with chronic HIV infection are to be integrated into society.

People with obstructive sleep apnoea have an increased mortality from cardiovascular disease, and one factor seems to be enhanced coagulability of the blood. This in turn may be associated with an increase in platelet activation ( Chest 2004;126: 339-41[Free Full Text]). The change in the platelets may be reversed by treating patients with continuous positive airway pressure. Clearly, further research is needed to evaluate the interventions that might be expected to lower the risks for people with this common disorder.

Minerva is a collector of coarse epidemiology—interesting facts that anyone can understand. Her latest figures are the change in mortality from cardiovascular disease in the United States since 1970 ( American Journal of Medicine 2004;117: 219-27[CrossRef][ISI][Medline]). In 1970 the age adjusted mortality was 448/100 000, and this declined to 186/100 000 by the year 2000—a reduction of more than half. The decline was seen in men and women and in both black and white people. As to an explanation, the answer seems to be a combination of a fall in the incidence of the disease and a reduced case mortality. Whatever, it's a big change.

This well 64 year old woman presented after her young grandson had accidentally knocked her forehead. She also gave a history of minor gum bleeding. There was no relevant drug or medical history. However, clotting tests showed an international normalised ratio of 5.8 and a twice normal activated partial thromboplastin time, which was corrected with normal plasma. The haemophilia centre found deficiencies of factors II, VII, IX, and X. It transpired that the woman had handled mouse poison six weeks earlier. Difenacoum, detected in her blood samples, can be absorbed through skin, with prolonged anticoagulant effects. The patient received oral vitamin K for three months. Exposure to rodenticides can cause unusual, potentially serious bruising and bleeding. Carol Barton (Carol.barton{at}sbucks.nhs.uk), consultant haematologist, Wycombe Hospital, High Wycombe HP11 2TT, Gurjit Dhesi, general practitioner, Calcot Medical Centre, Chalfont St Peter SL9 9SA, Paul Giangrande, consultant haematologist, Oxford Haemophilia Centre, Churchill Hospital, Oxford OX3 7LJ

Another statistic that is worth further investigation is in a report in the British Journal of Surgery ( 2004;91: 1197)[CrossRef][ISI][Medline]. This describes 4231 patients with early gastric cancer treated in Japan, with a disease specific survival of 98.4% at five years. The most important adverse prognostic factor was age rather than spread to lymph nodes.

Motor development is slower than average in children who are profoundly deaf from birth: they walk later and balance less well. Research in Spain ( Developmental Medicine and Child Neurology 2004;46: 599-606[CrossRef][ISI][Medline]) has now shown that treating very deaf children with an early cochlea implant improves their motor abilities and produces subtle differences in their neuropsychological development. The practical conclusion is that the earlier a cochlea implant is inserted the better.

CiteULike    Complore    Connotea    Del.icio.us    Digg    Reddit    Technorati    What's this?