MinervaBMJ 1995; 310 doi: http://dx.doi.org/10.1136/bmj.310.6975.340 (Published 04 February 1995) Cite this as: BMJ 1995;310:340
Around 10% of patients on dialysis who die have their dialysis stopped before death. Discontinuation of dialysis for a patient with a terminal illness sets a time limit for the process of dying (Archives of Internal Medicine 1995;155:42–7). If all goes well the patient and the family can talk candidly; dietary restrictions can be lifted, and many patients die “a good death.” Not all do, however: some have poor palliative care and may have substantial distress.
The new year toast in the “British Heart Journal” (1995;73:8–9) was to the cardioprotective effects of alcohol. M J Griffith blames the temperance mentality for blurring the message. We should, he says, advise the public to “consume one or two drinks a day, preferably with meals and perhaps red wine. Patients already drinking at this level should be encouraged to continue, and lifelong teetotallers should be informed of the hazards of their continued abstinence.”
Minerva's 1995 prize for prolixity goes to the Edinburgh Conference Centre's sign—“TOILET FLUSH. To flush the toilet please operate the handle in upwards direction.” Why not “Lift to flush?”
Minerva started her journalistic career as an editor of a student medical journal, so she is pleased to report that the January issue of the “St Mary's Gazette” (1995;101:3–4) celebrates 100 years of publication of this journal, which has a current circulation of 2800 to students, staff, and “influential personages.”
When someone lies on one side it is the upper side of the body that sweats. This observation made by an Indian surgeon was confirmed in the department of physiology, Goa Medical College, using measurements of galvanic skin resistance (Indian Journal of Physiology and Pharmacology 1994;38(4):319–22). The explanation seems to be that posture influences the sympathetic cholinergic outflow; the physiological purpose of the phenomenon remains uncertain.
People who sustain whiplash injuries in traffic accidents may develop a form of retinal angiopathy due to indirect trauma. A report in “Eye” (1994;8:615–7) describes three cases, warning that the problems with vision may persist long after the fundal appearances have returned to normal or near normal. Fluorescein angiography may show up defects months or years after the original trauma.
A prospective study of 826 children in Tucson, Arizona, found that by the age of 6 just over half had never wheezed (New England Journal of Medicine 1995;332:133–8). One fifth had had at least one lower respiratory illness with wheezing before the age of 3 but had no wheezing at 6 years; only 14% had had wheezing both before the age of 3 and at 6 years. Children who started wheezing early in life and continued to wheeze at 6 years were more likely than the others to have mothers with a history of asthma, to have raised serum IgE concentrations, and to have impaired lung function at the age of 6. House dust mites and rhinoviruses are virtually unknown in the desert environment of Tucson.
Minerva liked a letter in “New Scientist” (7 January 1995, p 44) commenting on constipation in toddlers. In contrast with the computer buff's maxim “rubbish in, rubbish out,” anyone interested in child nutrition learns that “rubbish in” may often mean “no rubbish out.”
Everyone is agreed that old people with risk factors such as heart or chest disease should be vaccinated against influenza every autumn; yet fewer than half are protected (Postgraduate Medical Journal 1995;71:22–3). Putting up a poster in the waiting room is not enough, says the journal: doctors should seek out the patients who need the vaccine and arrange for the housebound to be given their injections at home.
Research in Gothenburg (Lancet 1995;345:84–6) has shown as many as 80% of women who have spontaneous abortions in the first trimester will recover without surgery if given the chance. In a randomised controlled trial 103 patients had expectant management and in 81 the pregnancy resolved spontaneously. The duration of vaginal bleeding was 1.3 days longer in the expectant group than in those women having dilatation and curettage, but there were no other differences.
The many methods now available for imaging the brain have been reviewed at length in the “Journal of Neurology, Neurosurgery, and Psychiatry” (1995;58:7–21). Most have potential risks, the article warns—and it concludes by endorsing the recommendation of the Royal College of Radiologists that if a clinician is in doubt “as to whether an investigation is required or which investigation is best it makes sense to ask the radiologists, who, like other consultants, will know much more about their specialty than those whose primary interests are in other fields.”
A fatal attack by four terriers on their owner, a woman aged 67, is described in Injury (1995;26:37–41) as one of seven examples of attacks by dogs acting as a pack. Most dog bites cause only minor injuries, but the article warns of the “extreme danger” when dogs bred for hunting come together in groups which may stimulate pack instincts.
Some of the so-called contraindications to hormone replacement treatment for menopausal women need to be scrapped, says an editorial in the “Scottish Medical Journal” (1994;39(6):165). In particular, there is no increased risk of venous thrombosis with the treatment, which may be given safely to women who have had a deep vein thrombosis or a pulmonary embolism. Women on treatment do not need to stop it before having elective surgery. Neither varicose veins nor obesity should rule out the treatment.