BMJ  2006;333:978 (4 November), doi:10.1136/bmj.333.7575.978

Minerva

Minerva

It's easy to start drug treatment for an elderly patient, but somehow much more difficult to stop it. As a result, many old people are taking multiple medicines. Dependency and cognitive impairment diminish elderly people's capacity to report symptoms that might be due to adverse effects of drugs or drug interactions. A randomised controlled trial of a review of medication by a pharmacist versus usual general practitioner care found that although the intervention resulted in substantial changes in medication, the number of drugs remained the same. The biggest benefit to the patients was that their risk of falling was reduced (Age Ageing 2006;35: 586-91[Abstract/Free Full Text]).

Pemphigoid gestationis may be difficult to distinguish from polymorphic eruption of pregnancy, as both conditions often present in late pregnancy with an intensely itchy urticated eruption. Pemphigoid gestationis is important as lesions progress to frank blisters, and it is associated with premature delivery and recurrence in subsequent pregnancies. Clinical examination can often help differentiate the two diagnoses, as pemphigoid gestationis involves the umbilicus (top) whereas polymorphic eruption of pregnancy develops in the striae and spares the umbilicus (bottom). Pemphigoid gestationis can be confirmed by immunofluorescence, which shows a linear band of C3 or immunoglobulin G, or both, at the basement membrane. Joanne Hague, specialist registrar (joannehague{at}doctors.org.uk), Bruce Gee, consultant, department of dermatology, South Warwickshire General Hospitals NHS Trust, Warwick CV34 5BW

A few years ago, many people believed that functional analysis of human genes would explain why the therapeutic effectiveness and toxicity of drugs varied between individuals. It was expected to revolutionise rational drug use. A recent article (Pharmacological Review 2006;58: 521-90 http://pharmrev.aspetjournals.org/cgi/content/full/58/3/521[Abstract/Free Full Text]) discusses why the idea still hasn't made it to clinical reality. A case for routine genotyping or phenotyping before giving drugs can be made for very few—most convincingly for thiopurines such as azathioprine.

Minerva can't recall ever having heard the phrase "armchair theorist" used in anything but a pejorative way. So, as someone partial to an ironic view of life, she was enchanted to read a defence of this sort of thinking (Planning Theory 2006;15: 203-7). It's written in fancy language but the meaning is fairly clear: without the time and opportunity to contemplate what the results of research might mean, they lose much of their value.

In Canada, deaths in children from injury or poisoning have fallen substantially over the past 50 years. Rates continue to be higher in disadvantaged children, but the decline over time has been steepest for children from families in the lowest income groups. It's encouraging to find an instance where socioeconomic disparities in health are actually diminishing (CMAJ 2006;175: 867-8[Free Full Text]).

More than 10% of people develop ventricular fibrillation in the early hours after acute myocardial infarction. The difficulty of predicting who is at risk is, of course, one reason why such patients need intensive monitoring. A meta-analysis of nearly 60 000 patients with myocardial infarction doesn't get us much further forward. The only strong risk factor was ST segment elevation on the admission electrocardiogram. Sex, age, and site of the infarct had only a small influence (European Heart Journal 2006;27: 2499-510[Abstract/Free Full Text]).

Intracytoplasmic sperm injection is now a widespread assisted reproduction technique for couples struggling with male infertility. Concerns remain about long term medical and developmental outcomes in children conceived with this technique. A study of 151 such children finds their intelligence and their motor, balance, and ball skills are at least as good as those of a comparison group of children conceived without medical intervention (Human Reproduction 2006; 21: 2922-9[Abstract/Free Full Text]).

Enthusiasts for complementary medicine often claim that the reason why it never seems to work when tested in randomised controlled trials is that treatment has to be individualised to the patient. The investigators in a trial of acupuncture in essential hypertension anticipated this excuse when they allocated participants at random to either individualised traditional Chinese acupuncture, standardised acupuncture at preselected points, or invasive sham acupuncture. After six weeks' treatment, the decrease in blood pressure was similar in all groups (Hypertension. 2006;48: 838-45[Abstract/Free Full Text]).

Stimulated by observations from the laboratory that nicotinic acetylcholine receptors are important in eye development in chicks, a group of investigators decided to survey patients and parents at their paediatric ophthalmology clinic. Myopia was strikingly less common in children with parents who smoked—evidence, they think, that this receptor is important in eye development in humans too (Investigative Ophthalmology and Visual Science 2006;47: 4277-87[Abstract/Free Full Text]).

Several epidemiological studies have suggested that statins have a chemoprotective effect against cancer. Sadly, a meta-analysis of data collected in 35 randomised controlled trials (Journal of Clinical Oncology 2006;24: 4808-17[Abstract/Free Full Text]) now makes this look a forlorn hope. Cancer risk was neither increased nor decreased among over 100 000 participants. Why the divergent findings? The likely explanation is that associations between statin use and cancer in observational studies were confounded by social and behavioural factors.

Doctors tend to discuss decisions about cardiopulmonary resuscitation in elderly patients with relatives rather than with the patients themselves. Part of the reason is that the conversation gets deferred until the patient is too ill to make this decision. One solution would be to institute a routine of assessing resuscitation preferences and goals of care at the time of admission (Quarterly Journal of Medicine 2006;99: 711-5[Free Full Text]).

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