BMJ  2004;329:E330 (16 October), doi:10.1136/bmj.329.7471.E330

BMJ USA: Minerva

Minerva

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 immunization might reduce morbidity and deaths linked to influenza and other viral pneumonias in children and adults ( Nature Medicine 2004;doi:10.1038/nm1077).

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

Though Minerva rarely manages to squash mosquitoes, she derives great satisfaction when she does. But US doctors say it's better to flick mosquitoes off skin, rather than squashing them, after a 57 year old woman died from an extremely rare fungal infection called Brachiola algerae, which she developed after swatting a mosquito. The fungus is not carried in mosquito saliva, so it's not passed on in bites, but swatting the insect caused part of it to penetrate and infect her skin ( New England Journal of Medicine 2004;351: 42-7[Free Full Text]).

One possible reason that female athletes have such a high rate of anterior cruciate ligament injuries could be the vagaries of the menstrual cycle. But a study in the American Journal of Sports Medicine ( 2004;32: 1150-7)[Abstract/Free Full Text] says that ligament laxity in knees is not significantly affected by the follicular, ovulatory, or luteal phases of the menstrual cycle. Nor did it find that bicycling exercise exacerbates or creates any differences in ligament laxity.

Psychological insulin resistance (PIR), unlike physiological insulin resistance, is what patients with type 2 diabetes often put up when they're told they need to start taking insulin. Apart from anxiety related to injections, several factors contribute to PIR. They include a perceived loss of control over life, lack of self confidence in handling insulin, personal failure ("I must have messed up"), perceived severity of diabetes, and perceived lack of positive gain. All of these can be overcome if discussions about insulin treatment start early enough ( Clinical Diabetes 2004;22: 147-50[Free Full Text]).

Not so long ago, doctors were being encouraged to treat women with uncomplicated urinary tract infections with just three days of antibiotics. Anecdotal evidence suggests this isn't always effective, and a population based retrospective cohort study from the Netherlands backs this up. Treatment failure after three days of trimethoprim and nitrofurantoin was 14.4%, and it was 9.6% in those treated with norfloxacin. Further analysis of the data from more than 16 000 women points to five day and seven day courses being more effective ( British Journal of Clinical Pharmacology 2004;58: 184-9[CrossRef][Web of Science][Medline]).

The enormous swirling clouds of dust, soot, and exhaust that rose in the air for months after the collapse of the World Trade Center contained carcinogens which are now thought not to have put New York residents at risk of cancer. Researchers monitored air samples collected for 200 days after September 11, 2001, checking their concentrations of nine carcinogenic polycyclic aromatic hydrocarbons (PAHS). The researchers found that high levels of these chemicals were only transient, suggesting that increased cancer risks over a lifetime are unlikely (www.PNAS.org/cgi/doi/10.1073/pnas.0404499101).

A 42 year old man presented with an enlarging, friable mass on the dorsal aspect of the right third toe, extending onto the foot. He was taking immunosuppressive drugs (tacrolimus, mycophenolate mofetil, and prednisolone) after a lung transplant. A squamous cell carcinoma was suspected, and biopsy showed granulomatous inflammation and abundant fungal organisms. Trichophyton mentagrophytes var interdigitale was cultured. The lesion resolved completely after surgical debulking and oral terbinafine. Organisms of relatively low pathogenicity can present in a highly atypical fashion in immunosuppressed patients. Susannah Hoey specialist registrar Keith Armstrong consultant department of dermatology Ivan Stirling consultant surgeon Craigavon Area Hospital, Craigavon BT63 5QQ, UK

An emergency medicine specialist on a mountain hike came across a man with chest pain and a history of supraventricular tachycardia. When carotid sinus massage failed, the options available were ocular massage (with a risk of retinal detachment) and vigorous rectal massage (which he'd recently read about). Deciding between gloveless rectal massage or pressing on the man's eyeballs wasn't difficult: he went for the eyes. Fortunately for both, the distressed man immediately developed a strong pulse and his pain disappeared ( Academic Emergency Medicine 2004;11: 842-3[CrossRef]).

According to Quality and Safety in Health Care ( 2004;13: 315-6)[Free Full Text], the first randomized trial in medicine took place in Michigan, at the Detroit Municipal Tuberculosis Sanatorium, in 1926. It was a trial of sodium gold-theosulphate, a treatment for tuberculosis, and the randomization process consisted of the highly complex maneuver of flipping a coin. The outcome within the treatment group was no better than the control group, and the treatment was abandoned.

Half of all deaths in road crashes occur within one hour of the incidents, so it's clear that getting people out of wrecks quickly is critical. A Norwegian team has developed a "rapid extraction technique" based on reversing the forces of the original crash by anchoring the rear of the vehicle, and pulling the steering wheel and the front window pillars forward with chains. The time taken to get injured people out was significantly less than using standard techniques, and avoiding uncontrolled movements in the wreck was no more difficult ( Injury 2004;35: 739-45[CrossRef][Web of Science][Medline]).

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