BMJ  2005;330:1338 (4 June), doi:10.1136/bmj.330.7503.1338

Minerva

Given plenty of information, fewer than 20% of women eligible to take tamoxifen to reduce the risk of breast cancer and who perceived themselves to be at very high risk of the disease decided to take the drug. Researchers interviewed 250 women about their attitudes towards taking tamoxifen and found a mean self perceived five year risk of breast cancer of 32.7%. Women with very high perceived risk were no more likely to choose tamoxifen than those with the lowest perceived risk, and adverse side effects were the main reason for declining it ( Cancer 2005;103: 1996-2005[CrossRef][ISI][Medline]).

Conducting "talking therapy" at arm's length is meaningless, says a writer in the South African Medical Journal ( 2005;95: 318-20). If we keep the desk between ourselves and the patient, the best we can offer is listening with "one ear." It's like the matador in the ring needing to feel the breath of the bull on his face. Anything less is instantly picked up by the crowd, and people will jeer and throw things into the ring.

Abnormal metabolism could explain the finding of vascular disease in people who don't smoke and who don't have raised cholesterol concentrations. Animal studies have shown that overexpression of a gene involved in producing energy from respiratory oxygen in vascular tissue caused a rise in oxidative stress in arterial walls, which in turn caused a rise in blood pressure and the formation of atherosclerosis ( Nature 2005; 435: 502-6[CrossRef][Medline]). Nutritional strategies might be the best way to help fight heart disease in such people.

Substantial changes in painting style were the main consequence of minor posterior strokes of two professional artists. Features of these changes were analysed neurologically and psychiatrically. One painter showed mild visual-perceptive difficulties with increased anxiety and difficulty in emotional control and had switched to a more stylised and symbolic art form. The other, who also had issues of emotionalism, had switched to producing more joyous, simplistic, abstract art ( Journal of Neurology, Neurosurgery and Psychiatry 2005;76: 797-803[Abstract/Free Full Text]).

When you're dealing with an acute myocardial infarction, the question of whether the patient is also depressed doesn't often crop up. But with the recognition that depression has a large effect on health outcomes in patients with heart disease, being able to identify it is critical. A study of doctors and nurses caring for patients with myocardial infarction reports that depression is underrecognised in the absence of formal screening and that screening for depression should become routine for heart patients ( Psychosomatic Medicine 2005;67: 393-7[Abstract/Free Full Text]).

Some people believe that childhood immunisations influence children's subsequent development of allergies. Pertussis vaccine, for example, is thought to be positively associated with allergies and BCG to provide protection. But a case-control study of more than 7000 children found that neither the triple vaccine (diphtheria, tetanus, and pertussis) nor MMR (measles, mumps, and rubella) increases the risk of hay fever; nor did BCG reduce the risk. Late immunisation seems to reduce the risk, but this could be related to another factor, such as a febrile illness, causing both postponement and reduced risk ( Archives of Disease in Childhood 2005;90: 567-73[Abstract/Free Full Text]).

Is it more cost effective to introduce free nicotine replacement therapy or implement smoke-free workplaces? Working through the figures for a single US state shows that after one year a nicotine replacement therapy programme would result in 18 500 people quitting at a cost of $7020 (£3830, 5570) per person, while a smoke-free workplace policy would result in 10 400 people quitting at a cost of $799 each. With a ninefold difference in cost, smoke-free workplace policies are clearly the way to go ( American Journal of Public Health 2005;95: 969-75[Abstract/Free Full Text]).

Achieving the correct orientation of the acetabular component seems to be critical in reducing the risk of dislocation after total hip replacement. Researchers conducting a radiological analysis of hips that had dislocated found that setting the acetabular cup at an anteversion of 15° and an abduction of 45° provides the lowest risk of dislocation ( Journal of Bone and Joint Surgery 2005;87B: 762-9).

Patients who have had autologous haematopoietic cell transplants for some haematology malignancies have death rates that approach those of the general population after 10 years. But a report from the bone marrow transplant survivor study says that long term survivors continue to face challenges that affect their health and wellbeing. In particular, they're more likely to report difficulty in keeping jobs and obtaining life insurance compared with their siblings ( Blood 2005;105: 4215-22[Abstract/Free Full Text]).

Homeless adults in North America don't have higher rates of diabetes, hypertension, and high cholesterol than the rest of the population; it's just that the control of their conditions is worse and their smoking rates are higher, resulting in cardiovascular disease being the leading cause of death in this group. When 202 randomly selected homeless people from shelters in Toronto agreed to be interviewed (89% were men; the mean age was 42), 15% reported cardiovascular disease. Only a third said they were taking aspirin or cholesterol lowering drugs ( Circulation 2005;111: 2629-35[Abstract/Free Full Text]).

A 66 year old woman was referred to the dermatology department with striking changes affecting her lower legs. They looked as if they had been encased in cardboard. Several years earlier her legs had been bandaged to treat varicose eczema, and the bandages were changed infrequently. This interfered with the normal process of desquamation, resulting in a build-up of keratin (retention hyperkeratosis). She was treated with gentle debridement after soaking with arachis oil, revealing normal skin underneath. Recurrence of this benign but often malodorous condition is prevented by skin care with emollients. Ashley J Cooper (ajc{at}soton.ac.uk), specialist registrar, Caroline J Morgan, specialist registrar, Peter S Friedmann, professor, Dermatology Department, Royal South Hants Hospital, Southampton S014 0YG

Sometimes the old ways are still the best. The final report of a national prospective audit of tonsillectomies in England and Northern Ireland found that the rate of postoperative bleeding is at least twice as high when "hot" techniques such as diathermy are used to remove the tonsils and seal the area, compared with "cold" techniques that use traditional surgical equipment, packs, and ties. Guidance published in March 2004 that trainees should learn traditional techniques of removing tonsils before learning how to use diathermy, and that they should take more care, had an immediate effect on the complication rate (www.tonsil-audit.org).