BMJ  2005;330:204 (22 January), doi:10.1136/bmj.330.7484.204

Minerva

Catching and treating congenital hypothyroidism early is thought to produce a favourable outcome, but a study in Pediatrics ( 2005;115: e52-7)[Abstract/Free Full Text] shows that even when there are similarities in genes and environment, children treated for congenital hypothyroidism don't do as well as their siblings. In long term follow up, affected and nonaffected children were tested at the same time and given the same tests. In the past, critics have pointed to disparities in testing as being the cause of any differences found.

The development of physical alcohol dependence is partly related to the effect of alcohol on NMDA (N-methyl-D-aspartate) receptors in the brain. US scientists found that long term administration of alcohol followed by alcohol withdrawal caused increased production of a protein called tissue plasminogen activator (tPA) within the brains of mice. tPA interacts with a specific unit of the NMDA receptor, and this link is thought to promote alcohol dependence. Targeting this interaction with therapeutic agents might protect against some of the effects of alcohol misuse (www.pnas.org/cgi/doi/10.1073/pnas.0406454102).

Doctors are notoriously bad at taking time off work when they're sick, but this behaviour could lead to serious personal cost. Another analysis of the Whitehall II study reports an association between "sickness presenteeism" and serious coronary events. During the three year follow up period of the study, 17% of unhealthy male British civil servants took no time off work. The incidence of non-fatal and fatal myocardial infarcts over nine years was twice as high in this group as in unhealthy employees who had taken a moderate amount of time off work. Employers take note ( American Journal of Public Health 2005;95: 98-102[Abstract/Free Full Text]).

Some compulsive gamblers benefit from taking selective serotonin reuptake inhibitors, but those with a bipolar disorder may relapse despite such treatment. A randomised double blinded placebo controlled trial of sustained release lithium treatment over 10 weeks found that those who took lithium had significantly more control over their gambling urges, and their mood was more stable (particularly, improved mania ratings) than had those who received placebo. The authors say it's worth identifying gamblers who fall on the bipolar spectrum and offering them lithium ( American Journal of Psychiatry 2005;162: 137-45[Abstract/Free Full Text]).

The bubble of clinical "big science" and its funding boom has overexpanded and looks set to burst, according to writers in QJM ( 2005;98: 53-5)[Abstract/Free Full Text]. The era of scientific breakthrough in physics was followed by huge increases in funding, but the diminishing returns on this investment led eventually to a collapse in funding. Similarly in medicine: despite prolonged funding of the "basic to applied" model of clinical innovation, the rate of important therapeutic breakthroughs has been declining over the past 30 years.

Although patients are more likely to be anxious in the emergency department and, with little prior knowledge about the patients, there are likely to be diagnostic uncertainties, patient controlled analgesia has proved just as effective and as safe as nurse titrated analgesia. Satisfaction with the experience of pain relief in the emergency department was similar in both groups, but 20% of the patient controlled analgesia group reported mild sedation, compared with 7% in the control group ( Emergency Medicine Journal 2005;22: 25-9[Abstract/Free Full Text]).

Last week Minerva mentioned duodenal perforation caused by taking too much ibuprofen. Another case report discusses near-fatal hypokalaemia from misuse of Nurofen Plus, a non-steroidal antiinflammatory agent containing ibuprofen and codeine phosphate. A 45 year old woman presented three times with drowsiness and weakness, and was each time found to have a low serum potassium level. She was diagnosed as having renal tubular acidosis with renal potassium wasting, which was eventually put down to her admitted regular use of massive amounts of this over the counter preparation ( Journal of the Royal Society of Medicine 2005;98: 21[Free Full Text]).

Survival in patients with Parkinson's disease is less than in the general population. A 13 year follow up of 800 patients with Parkinson's disease enrolled in a drug trial found that neither sex nor age influenced overall survival. A poorer response to levodopa was a significant predictor of shorter survival regardless of the severity of the disease at the time of starting treatment, and regardless of the dose used ( Neurology 2005;64: 87-93[Abstract/Free Full Text]).

Rice bran, a product of milled rice, and its oil may offer cardiovascular benefits. In a study of 26 healthy volunteers, it turned out that the oil, and not the fibre, lowered cholesterol levels. The only substantial differences in the fatty acid composition of the diets they ate were in the oil and fibre. With consumption of the rice bran oil, low density lipoprotein dropped by 7%, whereas the healthy high density lipoprotein remained unchanged ( American Journal of Clinical Nutrition 2005;81: 64-8[Abstract/Free Full Text]).

Data from the ALSPAC study (Avon longitudinal study of parents and children) link the use of chemical based domestic products during pregnancy to childhood wheezing. Four wheezing patterns were established for the period from birth to 42 months: never wheezed, transient early wheeze, persistent wheeze, and late onset wheeze. Frequent use of chemical products was associated with persistent wheezing during early childhood, but not the other groups ( Thorax 2005;60: 45-9[Abstract/Free Full Text]).

A 53 year old man presented with an ulcer on the sole of his left foot, attributed to a possible penetrating injury three months previously. Macular irregular pigmentation 4 cm in diameter surrounded the area. Biopsy of the ulcer showed acral lentiginous melanoma, with melanoma in situ in the adjacent area. This tumour is diagnosed most frequently in the seventh decade and is an unusual variety of melanoma in white people, but the commonest form of melanoma in other races. B P Amirtha Vani (Amirtha_vani{at}yahoo.co.uk), specialist registrar, Frances Humphreys, consultant department of dermatology, Warwick Hospital, Warwick CV34 5BW

 

How quickly does new evidence filter down into practice? A study in The Oncologist ( 2005;10: 15-21)[Abstract/Free Full Text] charts what happened among oncologists when news broke about the benefit of aromatase inhibitors in treating post-menopausal women with hormone receptor positive early breast cancer. Structured interviews with practising medical oncologists showed that within two years they significantly increased hormonal therapy, with a concomitant decline in the use of tamoxifen. When the main tamoxifen trials were published in 1983, dissemination into practice took about five years.

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PD Survival

Camille B Carroll
bmj.com, 3 Feb 2005 [Full text]