BMJ  2006;332:862 (8 April), doi:10.1136/bmj.332.7545.862

Minerva

Minerva

"Do not resuscitate" orders raise the issue of whether an attempt to resuscitate is considered "medically futile." The question about futility, however, is rife with value judgments. The question is, whose values are they? And is success judged by the value placed on life itself, or quality of life by the person who is defining success? A discussion of all the issues is presented in the first issue of a new journal published by the Royal Society of Medicine: Clinical Ethics (www.clinicalethics.co.uk).

Regression analysis reveals three independent risk factors in women under 70 who develop giant cell arteritis: an early menopause, low body mass index, and smoking (Annals of the Rheumatic Diseases 2006;65: 529-32[Abstract/Free Full Text]). These results suggest its pathogenesis probably involves oestrogen deficiency. Commenting on recall bias, the authors say it's unlikely to be high as the events asked about are central to a woman's life.

More tea in the intensive care unit? The high mortality in septic patients is mediated by bacterial endotoxins, which stimulate macrophages, which in turn release proinflammatory cytokines. Since green tea (Camellia sinensis) has been shown—in a dose dependent fashion—to attenuate the endotoxin induced release of one particular late stage cytokine (HMGB1), the authors propose that regular tea intake might reduce mortality from endotoxaemia (Medical Hypotheses 2006;66: 660-3[CrossRef][ISI][Medline]).

Doctors do it differently. Most people who kill themselves do so by overdose or by hanging, but a case study in the Journal of Clinical Forensic Medicine (2006;13: 92-5[CrossRef][Medline]) describes how a 50 year old doctor committed suicide by stabbing himself repeatedly over the femoral arteries in both groins. The uncommon injury pattern and the lack of hesitation injuries point to the man's anatomical knowledge, and therefore intention, say the pathologists who did the postmortem examination.

Flu is spread more by adults than children, according to a new 30 year analysis of influenza in the United States. Children push flu into households and into cities, whereas regional spread is brought about by adults commuting, although long distance travelling doesn't seem to be as relevant. The flu season tends to start in California, probably because this state has such a large population (www.sciencexpress.org, 30 March 2006).

A flourishing doctor-patient relationship is the key "unit" of medicine, and any health care system should exist to support it, according to a writer in the British Journal of General Practice (2006;56: 226-9). But many factors conspire against the relationship, including time scarcity, a loss of tolerance and trust, and an excess of expectation. Minerva thinks the present day NHS is itself a serious threat, with practice based commissioning creating enough divide and rule among doctors to have a considerable impact on relationships with patients.

In the 15 years between 1985 and 2000, deaths from coronary heart disease dropped by 47% in Ireland. Forty four per cent of this decrease can be put down to treatments effects and secondary prevention, and 48% to better trends in risk factors—specifically, the prevalence of smoking dropped by 25%, cholesterol concentrations by 30%, and blood pressure by 6%. These improvements, however, were offset by increases in obesity, diabetes, and inactivity (Journal of Epidemiology and Community Health 2006;60: 322-7[Abstract/Free Full Text]).

People who experience social phobia or spider phobia respond well to cortisol treatment. Phobias trigger the release of cortisol in the brain, which probably helps by impairing memory retrieval during the attack. A double blind placebo controlled study of phobic people showed that oral cortisol given an hour before being exposed to a fear stimulus resulted in the experience of less anxiety. Control subjects who reported the least anxiety released the most cortisol, which supports a feedback mechanism (Proceedings of the National Academy of Sciences 2006;103: 5585-90[Abstract/Free Full Text]).

Another observation about cortisol is that it declines when you give up smoking, and this has been linked with smoking relapse (Psychosomatic Medicine 2006;68: 299-306[Abstract/Free Full Text]). To investigate whether these changes still occur when nicotine replacement therapy is used, 112 volunteers who were trying to quit smoking and using 15 mg nicotine patches had their salivary cortisol levels measured regularly. Their cortisol declined, more so among the heavier smokers, and those with the lowest cortisol concentrations were more likely to relapse and to experience withdrawal symptoms and stress.

A comparison of epidural analgesia with peripheral nerve blocks after total knee replacement reports that, on the first postoperative day, 87% of the epidural group experienced side effects, whereas only 35% of the patients in the femoral and sciatic nerve block groups were affected. On the day of surgery, motor blockade was more intense in the operated limb in patients with peripheral blockade and in the non-operated limb in those with epidurals. Hospital stays were similar, however, as was control of pain on mobilisation (Anesthesia Analgesia 2006;102: 1240-6[Abstract/Free Full Text]).

A 58 year old woman returned from a holiday in the French Pyrenees with fever and a painless skin rash on her arms and legs. A tick had been removed from her head a week earlier, and an eschar was evident at the site. She was treated presumptively with doxycycline and recovered fully. Convalescent serology confirmed a diagnosis of Mediterranean spotted fever (boutonneuse fever). Its cause, Rickettsia conorii, is transmitted by ticks and is present throughout France, Spain, Italy, and the rest of southern Europe. The death rate is up to 5.6% in patients sick enough to be admitted to hospital. Eleanor Heylen, senior house officer, Emma Thompson, specialist registrar (ecthomson{at}doctors.org.uk), Ron Behrens, consultant, Hospital for Tropical Diseases, University College Hospital, London WC1E 6AU

The future safety of our ageing brains depends on maintaining cognitive leisure activities—but not watching television, says an editorial in Neurology (2006;66: 794-5[Free Full Text]). The biological mechanism is poorly understood, but one large Chinese study has found that watching television is associated with a 20% increased risk of developing cognitive impairment, whereas physical social activities were not related to risk.

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