BMJ  2005;330:372 (12 February), doi:10.1136/bmj.330.7487.372

Minerva

Given the caution exercised when prescribing methotrexate to patients, with frequent blood monitoring and in some cases supervision in hospital, Minerva was interested to read that a longitudinal study of 248 patients with rheumatoid arthritis treated with methotrexate over seven years found that the drug was rarely discontinued, and not often because of blood test abnormalities ( Annals of the Rheumatic Diseases 2005;64: 207-11[Abstract/Free Full Text]). In this study the probability of continuing to take methotrexate over five years was 79%; 10% of all patients stopped it permanently because of adverse effects, and a third of those who stopped did so because the drug didn't offer any benefit.

Better late than never? When the United States lost half its flu vaccine supply due to problems at Chiron Corporation, the Centers for Disease Control and Prevention (CDC) told states to restrict its use to people at high risk. But late last month the CDC released 3.1 million doses of flu vaccine from an emergency stockpile and urged everyone to get a flu shot (www.cdc.gov/flu/protect/lateseasonguidance.htm). Flu vaccines are reformulated annually depending on current strains, so they go to waste unless used. The US flu season peaks in February.

Working out the best and most appropriate healthcare technology for developing countries is an evolving area for discussion. If you're interested in the resource implications or want to add your own ideas and contributions to the forum, go to www.iee.org/OnComms/pn/healthtech/aht.cfm

Encouraging women to lose weight before becoming pregnant could independently prevent neural tube defects. Since 1997, flour has been fortified with folic acid in Canada. A study in Obstetrics and Gynecology ( 2005;105: 261-5)[Abstract/Free Full Text] now shows that the mother's weight before conception may be an independent risk factor for neural tube defects: before flour fortification came in, greater maternal weight was associated with a modestly increased risk of defects; after 1997, this effect was more pronounced.

The most powerful predictor of waiting times in emergency departments is the time of arrival. Analysis of data from more than 75 000 patients to see who waits longest and who leaves without being seen found that patients' characteristics were less important than the time of presentation. Arriving at night, on a Monday or Sunday, and during the autumn were linked to longer waits. Young men who self refer are the most likely patients to leave without being seen ( Emergency Medicine Journal 2005;22: 93-6[Abstract/Free Full Text]).

Young men also lose out when it comes to being tested for chlamydial infection. A survey of nurses based in primary care found that 90% of them do not examine male genitalia, and over 50% had never tested male patients for Chlamydia. Most said they'd be more motivated if they were trained and paid for the extra time they perceived the testing and contact tracing would take. Greater availability of urine tests for Chlamydia might help ( Sexually Transmitted Infections 2005;81: 31-3[Abstract/Free Full Text]).

Using magnetic nanoparticles tagged with antibodies to measure the concentration of amyloid beta derived diffuse ligands (ADDL), scientists sampled cerebrospinal fluid from 30 people, half of whom were known to have Alzheimer's disease. Those with Alzheimer's had significantly higher ADDL levels than those without the disease. This biological "barcode" assay is said to be 100 000 times more sensitive than other detection technologies, and it might help to differentiate the stage of the disease as well as diagnose it (www.pnas.org/cgi/doi/10.1073/pnas.0409336102).

Like mother, like daughter: the psychological distress of women who have breast cancer is significantly correlated with levels of distress experienced by their adult daughters. Mothers experience greater levels of distress than their daughters, but mothers with advanced disease and their daughters experienced more distress than those women with primary disease and their daughters. As well as being reflected in their psychological profiles, the daughters' distress was also indicated by their immunological profiles, which showed lower natural cytotoxic activity and higher cortisol levels than those who were less distressed ( Psychosomatic Medicine 2005;67: 64-71[Abstract/Free Full Text]).

A randomised controlled trial in a US emergency department comparing oral rehydration therapy with intravenous fluids in children with mild to moderate dehydration caused by gastroenteritis shows that oral rehydration therapy is no worse than fluids by the intravenous route at correcting the problem. Hospital admission was more likely to be avoided in children who were given oral rehydration, and it was started more quickly than intravenous fluids ( Pediatrics 2005;115: 295-301[Abstract/Free Full Text]).

An 80 year old man presented with a month long history of headache and a non-itchy, but exquisitely tender rash across his forehead. Computed tomography of his brain showed only an old infarct, but his erythrocyte sedimentation rate was markedly raised at 134 mm/h. We made a diagnosis of temporal arteritis, but such a cutaneous vasculitic rash as a manifestation of temporal arteritis is rarely encountered. All his symptoms improved dramatically with steroid therapy. Llinos G Roberts (llinosgroberts{at}hotmail.com), SHO internal medicine, Mushtaq Wani, consultant physician, Sharon Blackford, consultant dermatologist, Swansea NHS Trust, Swansea SA1 5AT

It makes intuitive sense that bone loss around a replacement joint would slow down if bisphosphonates were taken. A meta-analysis of six randomised controlled trials confirms this and also indicates that the benefits of bisphosphonates are greater when cement has been used to fix the prosthetic joint. But a word of warning before everyone undergoing arthroplasty is given bisphosphonates: none of the trials included in this analysis included data about clinically relevant outcomes or end points ( Journal of Bone and Joint Surgery 2005;87: 293-301).

A study where the outcome might have been guessed to have been positive, but in fact wasn't, is reported in Circulation ( 2005;111: 465-71)[Abstract/Free Full Text]. Dietary phytoestrogens (isoflavones and lignans—fruit, vegetables, nuts, and berries) are thought to lower the risk of cardiovascular disease, but a Dutch prospective study didn't find a protective effect of higher intakes of low dose phytoestrogens, although it suggested that smokers could put themselves in a better position with a higher intake of lignans. Stopping smoking would probably achieve far more.

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