MinervaBMJ 1996; 313 doi: https://doi.org/10.1136/bmj.313.7061.890 (Published 05 October 1996) Cite this as: BMJ 1996;313:890
Enthusiasm for pancreatic transplantation as a treatment for insulin dependent diabetes will have been set back by a report from Sweden (New England Journal of Medicine 1996;335:860-3) of two patients whose grafts eventually failed apparently because of autoimmune attack. The received wisdom had been that the immunosuppressive treatment used to maintain the transplant was enough to prevent any autoimmune damage to the islets of Langerhans. That may be so in most cases, but the question that will now have to be asked is how long pancreatic transplants may be expected to function.
Might a raised blood pressure be a risk factor for some types of cancer? A commentary in “Hypertension” (1996;28:321-4) identified seven prospective studies that had suggested links with carcinomas, especially of the kidney. The increased rates of cancer could be a side effect of antihypertensive drugs, with diuretics the main suspect— but yet again the conclusion is that more research is needed.
An investigation of variations from town to town of the incidence of cases of meningococcal meningitis came up with the unexpected finding that the highest rates occurred in the towns where more general practitioners prescribed erythromycin for upper respiratory tract infections (Epidemiology and Infection 1996;117:103-5). The most likely explanation, says the report, is that erythromycin may have eradicated the commensals that normally inhibit the growth of meningococci.
For years now, scientists in North America have been pursuing the target of a fat free substitute for fat. A brief comment in “Science” (1996;273:1495) says that the latest contender is made entirely from fibre sources such as the outer layers of oats and beans; these are ground and dried into an ultrafine powder that can absorb up to 24 times its weight in water, forms a gel that looks like fat, and has, apparently, no taste at all. It will be used in the manufacture of cakes and biscuits—which, fortunately for Minerva, are not among her favourite foods.
In the United States in the 1980s prior caesarean section and breech presentation were both taken as indications for caesarean delivery. Obstetricians are now having second thoughts. In a series of 846 consecutive term singleton breech presentations 613 women were thought suitable for a trial of labour (American Journal of Obstetrics and Gynecology 1996;175:18-23). There were no stillbirths; six of the eight neonatal deaths were due to major malformations. The report concludes that further trials are needed to settle the issue, which has been debated for at least 20 years.
The incidence of acute myocardial infarction is known to be higher on Mondays than on other days. An investigation of other cardiovascular events reported in “Circulation” (1996;94: 1346–9) looked at 683 patients who had had defibrillators implanted. Dangerous arrhythmias showed a clear peak on Mondays with a trough on Saturdays and Sundays. The Monday peak was absent in patients taking β blockers.
The nature of the Gulf war syndrome continues to be controversial, with some reviewers drawing analogies with illnesses that developed in survivors of previous major conflicts going back as far as the American civil war (Annals of Internal Medicine 1996;125:398-403). Disorders such as Da Costa's syndrome and soldier's heart, shell shock, and battle fatigue share symptoms with the more recent syndrome, including shortness of breath, headache, sleep disturbances, impaired concentration, and forgetfulness. This suggests a common aetiology.
Calcipotriol, a synthetic analogue of the active metabolite of vitamin D3, has been shown to be an effective treatment for psoriasis, but concern has been voiced about possible side effects. A review in the “British Journal of Dermatology” (1996;135:347-54) concludes that dangerous disturbances in calcium homoeostasis are possible if the drug is given in doses higher than those recommended by the makers or if it is given to patients with unstable or pustular psoriasis.
The distance a patient can walk in six minutes is a useful measure of the severity of heart failure (Chest 1996;110:325-32). A study of 45 patients found a good correlation between the distance walked and the peak oxygen uptake, and the test provides a reliable guide to short term survival. Long term outcome, however, is predicted more reliably by a maximum exercise test.
Suggestions that babies who sleep with their parents may be at increased risk of the sudden infant death syndrome have led to research into the effects of this practice. A study in Leicester (Archives of Disease in Childhood 1996;75:249-50) has found that babies who slept regularly with one or more parents had slightly higher rectal temperatures than those who slept alone. Whether or not the small increase in temperature has any clinical importance remains unknown.
Baron Larrey, who was Napoleon's surgeon and introduced crucial improvements in the treatment of wounded soldiers, is one of Minerva's heroes; so she was interested to learn that an organisation called “Les Amis de Baron Larrey” is trying to set up a museum to his memory in his birthplace, Beaudean. Perhaps the BMA will want to be represented at the opening, planned for around 18 months from now.
Each year in Britain around 40 000 patients have operations to replace their hip joints. The prostheses vary greatly in cost, but few comparative data are available. A study of 208 Charnley and 982 Stanmore total hip replacements (Journal of Bone and Joint Surgery 1996;78B:802-8) found no differences until after 10 years of follow up, when the Stanmore joints gave slightly better results. Other studies have found trends in the opposite direction. Setting up randomised controlled trials seems a daunting task.