BMJ  2005;330:974 (23 April), doi:10.1136/bmj.330.7497.974

Minerva

Drugs such as modafinil (an agent promoting wakefulness) are used to try to counteract the fatigue of multiple sclerosis (MS), but evidence for their efficacy is scant. A randomised, placebo controlled, double blind study of modafinil including 115 patients found no improvement after five weeks ( Neurology 2005;64: 1139-43[Abstract/Free Full Text]), although a randomised controlled crossover trial of aspirin in 30 patients with MS published in the same issue (1267-9) shows that the drug alleviated the problem. The authors propose that aspirin may work by blocking the output of the hypothalamus, which in turn affects the neuroendocrine and autonomic responses important in the perception of fatigue.

Patients with chronic breathing disorders tend to be quite anxious and are often depressed. In a cross sectional survey of over 1300 people 80% of them screened positive for depression, anxiety, or both ( Chest 2005;127: 1205-11[Abstract/Free Full Text]). The predictive value of a telephone screen test being positive was estimated to be 80%. What was more worrying in a population with such a high prevalence of anxiety and depression was the extent of untreated morbidity: just 31% were receiving help for their mental state.

Minerva wonders whether it's the technical challenge to surgeons or the advantage to patients that's fuelling the minimally invasive trend in surgery. A study of minimal incision techniques for total hip replacement surgery found that a blinded mini-incision approach performed by highly experienced surgeons did not improve early postoperative outcomes, including length of stay in hospital, compared with the standard approach ( Journal of Bone and Joint Surgery (Am)) 2005;87: 701-10).

Another growing trend is the use of high thoracic epidural anaesthesia for patients undergoing coronary artery bypass grafting. Experimentally this form of anaesthetic has been linked to reduced myocardial damage compared with general anaesthesia, but a prospective, randomised controlled study of the two methods found no differences in concentrations of troponin I between the groups ( Anesthesia and Analgesia 2005;100: 921-8[Abstract/Free Full Text]). The major advantage seems to be the time to extubation: the average time in the epidural group was 15 minutes, compared with 430 minutes in the patients given general anaesthesia. The epidural group also needed less postoperative analgesia.

Charles Darwin experienced 40 years of intermittent vomiting, pain, headaches, lethargy, skin problems, and depression after returning from his voyage on the Beagle. Some 20 doctors failed to find the cause of his mystery illness, and most concluded that it was of psychosomatic origin. Today's diagnosis, revealed in the Postgraduate Medical Journal ( 2005;81: 248-51)[Abstract/Free Full Text], suggests he had systemic lactose intolerance all that time. Not only was there a family predisposition to the same problems, but Darwin got better only when by chance he stopped taking milk and cream.

An interesting reversal of health inequality trends is illustrated by a large outbreak of measles in London in late 2001. In contrast to many childhood infections, the measles cases were clustered around the more affluent areas of the capital, and the investigators of the outbreak argue that transmission of the virus was facilitated by low uptake of the measles, mumps, and rubella (MMR) vaccine. In London, MMR uptake in 2001 fell to 73%, compared with 84% in the rest of the country ( Archives of Disease in Childhood 2005;90: 424-5[Free Full Text]).

It's not just diabetes and heart disease that threaten to overwhelm us if we continue to eat a high fat diet. An analysis of data from the nurses' health study now shows a relation between a high intake of 18-carbon polyunsaturated fatty acids linoleic acid and linolenic acid, and an increased risk of cataracts ( American Journal for Clinical Nutrition 2005;81: 773-9[Abstract/Free Full Text]). The association specifically relates to nuclear opacification, not cortical or posterior subcapsular cataracts, and the foods implicated include sunflower, corn, soya bean, and cottonseed oils.

In an era when MRSA (methicillin resistant Staphylococcus aureus) trips off the tongue almost as easily as the NHS, it might surprise readers that the issue is not just about dirty hospitals. The first case of an immunocompetent community acquired MRSA psoas abscess is described in Injury ( 2005;36: 569-72)[CrossRef][ISI][Medline]. The 74 year old man had fallen down the stairs, and was presumed to have sustained a fracture. On further questioning he reported a three month history of pain in his lower back, without evidence of infection. The abscess was found on magnetic resonance imaging after plain x rays showed a loss of vertebral height at L2.

"Clinical inertia" is a condition of doctors that may well compromise the health of their patients. A study of diabetic patients with high HbA_1c concentrations found that fewer than half of them had their drug regimens intensified, regardless of the specialty of the doctor monitoring them ( Diabetes Care 2005;28: 600-6[Abstract/Free Full Text]). Patients looked after by hospital doctors were more likely to be started on insulin. Data collection started one year after the publication of evidence indicating that tight glycaemic control is critical to prognosis, at a time when the evidence was widely disseminated and being discussed.

A 2 year old child presented with painless swollen wrists and ankles. x Rays showed the cupping and flaring of the epiphyseal-metaphyseal junction of the lower ends of long bones that is typical of rickets. Her 25-hydroxycholecalciferol concentration was 1.5 ng/ml. Nutritional rickets at this age is not uncommon in areas where maternal intake of vitamin D and calcium during pregnancy and lactation is very low. Pavanasam Velayutham (Drvelu1974{at}yahoo.co.in), consultant endocrinologist, Pankaj Mehta, consultant radiologist, Kovai Medical Center and Hospital, Coimbatore, India

Embolisation of the uterine artery is a newish approach for the treatment of fibroids. A French study that followed up 85 women who underwent the procedure reports a 17.2% recurrence rate at 30 months ( British Journal of Obstetrics and Gynaecology 2005;112: 461-5). The factors predictive of recurrence were size and number of fibroids, and most of the recurrences became apparent only after two years. The study authors say this is still a small risk, and that for most women, embolisation is preferable to open surgery.

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