MinervaBMJ 1996; 313 doi: https://doi.org/10.1136/bmj.313.7063.1024 (Published 19 October 1996) Cite this as: BMJ 1996;313:1024
Technical advances have made magnetic resonance imaging a sensitive and reliable diagnostic and screening test for breast cancer (British Journal of Surgery 1996;83:1316-8). Current methods are said to provide more diagnostic information than conventional mammography, to require no compression of the breast (and so cause no pain), and to be suitable for younger women with dense breasts. All that and no hazard from radiation: despite the greater costs, this seems a likely popular alternative to x ray mammography.
A report in the “New England Journal of Medicine” (1996;335:1001-9) describes a huge double blind trial of the treatment with pravastatin of 4159 survivors of acute myocardial infarction whose serum concentrations of cholesterol were in the average range (below 6.2 mmol/l). After five years 10% of the patients receiving active treatment and 13% of those receiving placebo had had another coronary event. No difference was found in overall mortality or in mortality from non-cardiovascular causes.
Meanwhile, evidence is growing that atheromatous disease should be seen as a chronic inflammatory condition (Heart 1996;76:293-4). The cause of the damage is thought to be oxidised low density lipoprotein, and the treatment being proposed is with the antioxidant vitamin E. The clinical research is still at an early stage, but it seems sensible for all of us to eat a diet containing plenty of the vitamin—found in green leafy vegetables and vegetable oils.
Surgeons in St Louis have for over eight years been treating intractable atrial fibrillation by a technique known as the Maze procedure, in which multiple incisions are made in the walls of the atria. Their report in “Annals of Surgery” (1996;224:267-75) says that 178 patients have been treated and that 93% were free of arrythmia at follow up. In those patients in whom the fibrillation returned, medical treatment was successful.
A study in Canada (Quality in Medical Care 1996;5:166-71) found that almost all patients waiting for coronary bypass surgery thought the system was fair but that younger patients and those who suffered economically by waiting were more upset than the rest. The authors suggest that more research is needed to determine whether these socioeconomic factors should be taken into account in determining priorities.
A report in “JAMA” (1996;276:1011-4) of a workshop on melatonin and sleep conducted at the National Institutes of Health says that the drug is being sold as a food supplement in the United States but is being used to treat insomnia and jet lag. The meeting heard anxieties about the sources of melatonin (possibly bovine pineal glands) and its side effects, which include vasoconstriction and depression. This is the free market working.
When a kitten from a pet store in Concord, New Hampshire, gave a positive result when tested for rabies after a brief illness, postexposure treatment was given to 665 possible contacts, whose average age was 14 (American Journal of Public Health 1996;86:1149-51). The cost of the vaccines and the immunoglobulin was over $1m, and local reactions were reported by 76% of the recipients. With hindsight much of the treatment was thought unnecessary—but doctors are understandably reluctant to withhold it.
Links between infection with mycoplasmas and rheumatoid arthritis were first proposed 60 years ago, but the evidence was thought unconvincing in the 1960s and ‘70s. Interest has been revived, however, by studies using the polymerase chain reaction. An editorial in the “Journal of Clinical Pathology” (1996;49:781-2) reviews recent studies which have found several species of mycoplasmas in the joints of patients with rheumatoid arthritis and with inflammatory joint disease of unknown cause. It concludes that the role of these organisms “can no longer be ignored.”
Between 1970 and 1985 a total of 1341 women in England and Wales died of complications of pregnancy or delivery (British Journal of Obstetrics and Gynaecology 1996;103:973-80). The four most common causes of death were hypertensive disease of pregnancy, pulmonary embolism, abortion, and ectopic pregnancy. Women born in west Africa and the Caribbean had greatly increased risks: one factor seems to have been that immigrants are commonly “poor attenders” for antenatal care.
Overheating is thought to play a part in the sudden infant death syndrome. Measurement of the sleeping metabolic rate in healthy infants in the first year of life (Archives of Disease in Childhood 1996;75:282-7) found wide variations—from 1.4 to 3.5 W/kg. The authors conclude that no guidance can be given to parents on the amounts of clothing and bedding advisable for the thermal comfort of an infant at a given room temperature.
The IgNobel prizes are awarded each year at Harvard for achievements that “cannot or should not be reproduced.” Most winners are too ashamed or embarrassed to accept the award: the winners of this year's prize for biology were happy to stand by their paper in the “BMJ” (Baerheim A, Sandvik H. The effect of ale, garlic, and soured cream on the appetite of leeches. 1994;309:1689).
Bed nets impregnated with an insecticide have been shown to be an effective means of reducing the frequency of malarial infection, and in 1992 the Gambia introduced a national programme to encourage people, and especially children, to use them (Health Policy and Planning 1996;11:292-8). A random sample of larger villages found that 77% of children aged under 5 were using the nets at night—but only the first year's supply of insecticide was funded from external sources. No one knows if the $200 000 a year can be found to keep the scheme going.
Among the many puzzling features of glaucoma is its occurrence in people whose eyes do not have a raised intraocular pressure. A review in the “British Journal of Ophthalmology” (1996;80:859-60) explains that the critical measure is the difference between the intraocular pressure and the systemic blood pressure. Patients whose blood pressure dips substantially at night may suffer a critical fall in the blood flow to the optic nerve.