BMJ  2005;330:738 (26 March), doi:10.1136/bmj.330.7493.738

Minerva

The failure to find a sole pathological event that triggers Alzheimer's disease hasn't deterred some from believing there's still an undiscovered single event that starts the whole process off. The recent demonstration of immunoglobulin and complement in brain tissue from people with Alzheimer's disease raises the possibility that the presence of anti-neuronal auto-antibodies found in serum (previously thought to be of no significance) points to it being an autoimmune disease. One possibility is that a critical dysfunction of the blood-brain barrier allows these auto-antibodies to access and kill their desired target cells ( Medical Hypotheses 2005;64: 458-63[CrossRef][ISI][Medline]).

People with bronchiectasis tend to develop progressive airways damage due to recurrent infections, inflammation, and enzyme activities, and often end up harbouring Pseudomonas aeruginosa. A 12 month randomised placebo controlled trial of inhaled steroid therapy (fluticasone) in 86 patients with bronchiectasis found that the treatment significantly reduced the volume of sputum produced but had little effect on purulence or frequency of sputum, or on results of lung function tests. Fluticasone was particularly beneficial in people infected with P aeruginosa ( Thorax 2005;60: 239-43[Abstract/Free Full Text]).

"Respectful Disposal" of the dead includes the thought that should go into where a postmortem incision is placed. The standard incision may pass from the base of the neck to the pelvis, but if it starts too high up, concealment may be impossible. Similarly, exposing the skull contents by cutting forward across the scalp can lead to needless distress. A pathologist writing in Pharos International (spring 2005, pages 44-5) suggests dispensing with tradition and starting the postmortem examination with the body face down.

Minerva wasn't all that surprised to read that people who work on merchant ships have a tendency to poor health caused by their lifestyle. In a historical cohort study from Denmark, seafarers were found to be at excessive risk of being admitted to hospital for major diseases, and that those who were more likely to be hospitalised due to lifestyle related diseases were also at higher risk of being hospitalised because of injury or poisoning ( Occupational and Environmental Medicine 2005;62: 145-50[Abstract/Free Full Text]).

The clot that proves to be the final straw and blocks a coronary artery, causing an acute myocardial infarction, may be days or weeks old. A histological analysis of blood clots removed during angioplasty within six hours after the onset of pain fell into three groups: "fresh" (less than a day old), "lytic thrombus" (1-5 days), and "organised thrombus" (more than 5 days old). In over half the patients examined, the clots were days or weeks old, confirming the suggestion that considerable time can elapse between plaque instability and the onset of symptoms ( Circulation 2005;111: 1160-5[Abstract/Free Full Text]).

Good news for Easter. Dark, rather than white, chocolate seems to have a blood pressure lowering effect. Some 15 happy, healthy volunteers who were randomly assigned to receive dark or white chocolate bars on 15 consecutive days showed that the dark variety produced a significant drop in systolic blood pressure, and also improved insulin resistance as measured by glucose tolerance testing, compared with white chocolate ( American Journal of Clinical Nutrition 2005;81: 611-4[Abstract/Free Full Text]).

Both animal and human studies have indicated that non-steroidal anti-inflammatory drugs (NSAIDs) may reduce the risk of developing lung cancer. A meta-analysis of 14 studies that explored this association, and which included a separate look at the nine studies that had been adjusted for the effects of smoking, supports a small protective effect of NSAIDs, which was stronger when smoking was taken out of the equation. The relation is probably not causal ( Chest 2005;127: 748-54[Abstract/Free Full Text]).

When faced with having to make rapid estimations of weight without a pair of scales to hand—for example, before administering weight related doses of drugs—ask the patient to guess his or her own weight. A study involving 458 patients found that patients guessed most accurately (91% were within 10% of actual weight), whereas doctors and nurses consistently tended to underestimate the patients' weights ( Academic Emergency Medicine 2005;12: 262-6[Medline]).

For people faced with taking antiepileptic drugs, it's not necessarily the efficacy of the newer drugs that distinguishes between them, but which is best tolerated. When healthy volunteers were allocated to take either topiramate or gabapentin, and then went through a battery of cognitive tests, it was the people who'd taken topiramate who were most negatively affected, and in some tests the effects were quite large. Gabapentin produced far fewer problems ( Neurology 2005;64: 792-8[Abstract/Free Full Text]).

A 26 year old woman presented with an enlarging 6 cm, firm, hypopigmented patch at the umbilicus which had appeared shortly after she had her "belly-button" pierced the previous year. A skin biopsy confirmed the clinical diagnosis of morphoea. Morphoea (localised scleroderma) can occur after skin trauma and radiation, and patients with existing scleroderma are at risk of developing further lesions at sites of subsequent trauma. These patients should be advised about the further risk of localised disease when considering cosmetic piercings. V J Lewis (vjlewis65{at}hotmail.com), specialist registrar, Royal Gwent Hospital, Newport, M M U Chowdhury, consultant, Welsh Institute of Dermatology, Cardiff

A novel alternative use for the disposable soft rubber ear tips routinely used during tympanometry is described in the Journal of Laryngology and Otology ( 2005:119: 38-9)[CrossRef][Medline]. The rubber ear tips apparently provide excellent protection to the delicate lining of nostrils, when placed over nasal prongs used in oxygen delivery. The domed end sits comfortably at the entrance to each nostril; the other end fits snugly over the nasal prong. The chance of the tips becoming dislodged is negligible, and they're a lot less irritating than bare prongs.

When copper and zinc levels of patients suffering from brucellosis were compared with healthy individuals in a study from Turkey, where the infection is rife, serum copper levels were significantly higher, and serum zinc levels were significantly lower. These tests aren't a proxy for looking for evidence of brucellosis, but in patients who don't feel great and have abnormal levels of copper and zinc it might be worth thinking about brucellosis ( Journal of Infection 2005;50: 31-3[Medline]).

Since the American Academy of Pediatrics produced guidelines in 1992 on placing babies on their backs to sleep, in an effort to reduce the rate of sudden infant death syndrome, the prevalence of plagiocephaly in the United States has risen from 1 in 400 to 1 in 10. Specially constructed protective head helmets designed to reshape the head have been used, although they're often unnecessary, expensive (over $2000 each (£1040; 1495)), and annoying for infants to wear ( Washington Post 2005, 8 March).

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