BMJ  2005;331:168 (16 July), doi:10.1136/bmj.331.7509.168

Minerva

A study of the effects on toddlers of home smoking bans shows that a policy of no smoking in the house is associated with a small but significant reduction in mean urinary cotinine:creatinine ratio in children aged 18-30 months. The reduction holds regardless of how much the parents smoke outside the home ( Archives of Disease in Childhood 2005;90: 670-4[Abstract/Free Full Text]).

A randomised, controlled, double blind study of the effects of candesartan (an angio-tensin receptor blocker) on 5436 patients with heart failure, who did not have diabetes at the start of the study, reports that 6% of those in the candesartan group subsequently developed diabetes, compared with 7.4% in the placebo group. It's not exactly news, because other large studies have shown similar effects with ramipril and enalapril, which are both ACE inhibitors. But the authors point out that this is the first study that compares the active drug with a placebo ( Circulation 2005;112: 48-53[Abstract/Free Full Text]).

A possible clue as to why melanoma cells are so resistant to chemotherapy has been reported by scientists in the latest issue of Nature ( 2005;436: 117-22)[CrossRef][Medline]. Using DNA chips to achieve ultra-high resolution of genetic analyses, they identified a distinct amplification of the gene that encodes for MITF (microphthalmia associated transcription factor) in melanoma cells. Treatments that specifically target this regulatory protein may prove fruitful, as MITF could represent the weak link in an otherwise seemingly unbreakable chain.

It's immoral to ban research involving human embryonic stem cells, argues a retired medical inspector of the Italian state railways. He bases his thesis on the fact that the concept of morality arose as a "selectively advantageous product of evolution" aimed at reducing suffering from the pain and afflictions brought about by diseases and impairments which tended to hasten the extinction of small ancestral groups. If in future humankind is threatened by a disease potentially curable only by the applications of stem cell research, apologies by religious leaders for the current pressures to ban this research are unlikely to console the bereaved survivors ( Stem Cells and Development 2005;14: 239-47[CrossRef]).

Surgeons of the Royal Navy during Nelson's era documented 446 presentations to the sick list of men with genitourinary symptoms. Gonorrhoea was treated with bed rest and cooling regimens, although astringent injections of white vitriol (zinc sulphate) or barley water under the prepuce or down the urethra were also prescribed. Preventive measures against venereal diseases included "washing the nut of the yard [glans] with a soft sponge and yellow soap after coition" ( Postgraduate Medical Journal 2005;81: 413-8[Abstract/Free Full Text]).

Perhaps a more surprising use of soap is discussed in the Journal of Bone and Joint Surgery ( 2005;87A: 1415-22). A prospective comparison of non-sterile soap solution versus antibiotic solutions to irrigate open fracture wounds of the legs found that, contrary to expectation, irrigation with antibiotic solution offered no advantages over soap and might increase the risk of wound healing problems.

The risk of HIV transmission from mother to baby is increased in preterm birth, and hypertension during pregnancy increases the risk of preterm delivery (as well as the risks of growth retardation and perinatal death). In a double blind, placebo controlled trial of multivitamin supplementation in 1078 pregnant Tanzanian women infected with HIV, those taking vitamins were 38% less likely to develop high blood pressure than those who took placebo. Taking multivitamins containing vitamins B, C, and E may be a cheap and effective strategy to improve the health of both mother and baby ( Journal of Nutrition 2005;135: 1776-81[Abstract/Free Full Text]).

A 78 year old woman was referred with painful nodules on her legs which had been present for three weeks. She was subsequently admitted with recurrent pancreatitis caused by gallstones and a pancreatic pseudocyst. Clinical examination revealed large tender erythematous nodules (some of which exuded a brown oily fluid) symmetrically distributed on her lower legs. Her serum amylase levels were raised at 4072 IU. We diagnosed pancreatic panniculitis, a well recognised but rare condition. The brown fluid represents liquefactive necrosis of adipose tissue due to the high levels of pancreatic enzymes released. The condition occasionally resolves on treatment of the underlying cause. Preshita Divekar (preshitadivekar{at}hotmail.com), specialist registrar, Michael Davies, consultant, department of dermatology, Derriford Hospital, Plymouth

There are many studies of "difficult patients," but very few about "difficult doctors." A correspondent in the QJM ( 2005;98: 542-3)[Free Full Text] says that one reason for the lack of information about "provider characteristics" is that doctors are not keen to be personally studied, and furthermore that an assumption seems to be made that only patients have emotions, attitudes, and characteristics (such as social class) that might influence the nature of communication. Focusing solely on difficult patients distorts what is actually a complex relational issue.

Carers come in all shapes and forms, but for many organisations the conventional images adopted are of heterosexual adults and couples learning to adjust to life changing circumstances. These can give the impression that some diseases affect only married couples or those with supportive families. Wondering if there was anyone else out there looking after a same sex, long term partner with Alzheimer's disease, one man wrote a letter to the Alzheimer's Society, and the result was the creation of a network of helpers who could be contacted by telephone to help support other gay callers. For more information go to www.alzheimers.org.uk/gay_carers.

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