BMJ  2005;330:1218 (21 May), doi:10.1136/bmj.330.7501.1218

Minerva

A woman who had had light periods and apparent contraception for four years after having a levonorgestrel intrauterine system (Mirena) fitted developed heavy, prolonged periods, and it was thought it was time for the device to be changed. The surprising thing was that it had worked at all, because gynaecologists eventually found the original device in the peritoneal cavity. Either it had migrated slowly over four years or—more interestingly—the local release of levonorgestrel in the ovarian fossa had brought about anovulatory cycles in the same way as the progesterone only pill ( Journal of Family Planning and Reproduction 2005;31: 163-4).

The leprosy bacterium grows in humans, armadillos, and the footpads of mice—but not in test tubes. A genetics study of strains of Mycobacterium leprae from patients around the world now shows that a single bacterial clone that has spread but barely mutated over time is responsible for the world's entire leprosy infection. It now looks as if leprosy originated in East Africa, and Europeans and North Africans took it to West Africa. The slave trade took it from there to the Caribbean and South America ( Science 2005;308: 1040-2[Abstract/Free Full Text]).

It's not just type A people who are prone to heart disease. If you're a "D" or "distressed" personality type you tend to experience negative emotions, and you inhibit these emotions by avoiding social interactions. Both of these are associated with greater cortisol reactivity to stress, which in turn may mediate the increased risk of coronary heart disease in D types. The question is, should D types be offered psychological or drug treatments to improve both their psychological and physical health? ( Quarterly Journal of Medicine 2005;98: 323-9[Abstract/Free Full Text]).

Inhibiting gastric acid is critical when managing active peptic ulcer bleeding that doesn't stop spontaneously. A randomised placebo controlled trial comparing treatment with infusing somatostatin and a proton pump inhibitor, found that both achieved high intragastric pH values compared with placebo, but that somatostatin was more effective during the first 12 hours of treatment. In this case, somatostatin is thought to work by inhibiting gastrin, in addition to its vasoactive effect of reducing bleeding ( Scandinavian Journal of Gastroenterology 2005;40: 515-22).

Prayer apparently does ease pain, according to a survey conducted by USA Today, ABC News, and Stanford University Medical Center. Over half the respondents said they use prayer as a form of pain relief, and 51% said it works "very well." Comparing it with a dozen different types of pain relief therapies, most respondents said that only prescription drugs work as well as prayer at relieving pain ( USA Today 2005;May 10: D.7).

The cause of death of a heart donor doesn't influence the recipient's survival after transplantation once confounding factors are adjusted for, according to a study of medium term survival after UK heart transplants ( Journal of Thoracic and Cardiovascular Surgery 2005;129: 1153-9[Abstract/Free Full Text]). The analysis picked out the donor's age, time to organ ischaemia, creatinine clearance of the recipient, the diagnosis of the recipient, peripheral vascular disease, ventilation, diabetes, and mismatch between donor and recipient regarding size as risk factors for early, late, and overall mortality.

The Black Death was not an epidemic of bubonic plague but a viral haemorrhagic fever with a long incubation period that allowed it to travel far despite the limitations of travel in the Middle Ages. Originating in Africa, and spreading to Europe and Asia, it may have left an important legacy. The CCR5-32 genetic deletion provides almost complete resistance to HIV-1 in homozygous people, and the average frequency of this deletion is estimated at 10% in the European populations ravaged by plague, but the deletion is virtually absent among sub-Saharan Africans and Asians and American Indians ( Postgraduate Medical Journal 2005;81: 315-20[Abstract/Free Full Text]).

The amount of vitamin C produced in breast milk can be increased dramatically by drinking fresh orange juice. A study in the American Journal of Clinical Nutrition ( 2005;81: 1088-93)[Abstract/Free Full Text] shows that the production of ascorbic acid in human milk increases most in women who have a low level to start with—such as African women. Over a period of six weeks, these women increased production of ascorbic acid in their milk from 16 mg/kg to 32 mg/kg by taking three servings of orange juice a week and from 21 mg/kg to 46 mg/kg by taking five servings. The increase seen in European woman was much more modest.

What women eat in pregnancy has also been under scrutiny recently. Looking at data from a large contemporary generally well nourished population, researchers wanted to see if they could find evidence of any effects of diet during late pregnancy on blood pressure in children aged 7.5 years. Contrary to results from several smaller studies, mostly done on people in unusual dietary circumstances, they failed to find any influence at all ( Archives of Disease in Childhood 2005;90: 492-3[Abstract/Free Full Text]).

A 58 year old renal transplant recipient who had been treated with ciclosporin since 1989 presented with progressive changes of the facial skin. The patient had numerous erythematous and yellowish papules and nodules as well as swelling and distortion of the nose (rhinophyma). Sebaceous hyperplasia is a recognised side effect of ciclosporin treatment, particularly on the skin of renal transplant patients when exposed to sunlight. Rhinophyma is a localised swelling of soft tissue with variable combinations of sebaceous hyperplasia, fibrosis, and lymphoedema. Treatment by surgical excision or physical ablation of the excess tissue may improve cosmetic appearance. Sara Brown (sara.brown{at}ncl.ac.uk), specialist registrar, Cliff Lawrence, consultant dermatologist, Aileen Taylor, consultant dermatologist, Royal Victoria Infirmary, Newcastle upon Tyne NE1 7RU; John Tapson, consultant physician, Freeman Hospital, Newcastle upon Tyne NE7 7DN

Minerva is always on the look out for interesting and educational pictures to publish. In response to some of the questions she often gets asked, Minerva veers away from very rare conditions and pictures showing foreign bodies. She also needs written consent from patients, no matter how difficult it would be to identify a patient from the text and picture. Any contributions should make their way to Minerva via Benchpress, the BMJ's electronic manuscript processing system (accessed on bmj.com).

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