Minerva

In this era of evidence based medicine, surgeons are urged to conduct randomised trials of new operations rather than rely on anecdotal reports. In the case of minimally invasive direct coronary artery bypass, says an editorial in Heart (1997;78:533-4), such a trial should be delayed until the participating surgeons have completed their climb up the learning curve—and until a clearer consensus has emerged on the optimum surgical technique.

Mary Poppins's advice that a spoonful of sugar helps the medicine go down is unpopular among dentists, who complain that the sugar in children's medicines is just as harmful to the teeth as the sugar in sweets. Some qualitative research (British Journal of General Practice 1997;47:823-4) asked parents for their views. Most left the decision whether to prescribe a sugar free medicine to the doctor, but a few mothers of children receiving long term treatment were prepared to be more assertive.

Australians are becoming concerned about a potential plague of European wasps, introduced to the country in 1977. A letter in the Medical Journal of Australia (1997;167:650-1) warns that these insects are dangerous because they have toxic venom, multi-stinging capacity, and aggressiveness on their side, and wasp stings are now a frequent cause of inquiries to poison centres. Politicians are developing a national European wasp strategy.

A retrospective study of 593 Dutch women who had had hysterectomies (Diseases of the Colon and Rectum 1997;40:1342-7) found that 315 had had normal bowel habits before surgery but that 90 of these had found an increased need to strain afterwards. Fifty had had to resort to digital evacuation. In a smaller comparison group of 58 patients who had had normal bowel habits before having laparoscopic cholecystectomy only five had reported problems with their bowels afterwards.

The lifetime risk of a child developing psoriasis if neither of the parents has the disease is 0.04; if one parent has it the risk rises to 0.28; if both have it the risk is 0.65. These data from Sweden appear in the British Journal of Dermatology (1997;137:939-42). The risks are increased if there is already one child in the family with the disease. Psoriasis seems to be inherited as an autosomal recessive, but the genetics are complicated by there being at least two independent inherited types of the disease, which are clinically indistinguishable

Minerva used to eat a lot of oysters before she developed an allergy to them, and so she is interested in the causes of viral gastroenteritis associated with oysters. In an outbreak in Louisiana reported in the Morbidity and Mortality Weekly Report (1997;46:1109-12) the pathogen was identified as a small round virus. The oysters had become infected because the crews of the vessels harvesting them discharged sewage from their boats straight into the sea.

A review of the evidence that eating fish protects against coronary heart disease (CHD) concludes that “merely adding fish to a nutritionally adverse diet will not grant a population immunity from epidemic CHD.” The answer, says the review (European Heart Journal 1997;18:1841-2), is to include the fish in a low fat, low cholesterol, high fruit/vegetable diet. There is no evidence that swallowing fish oils in pills has any protective effect.

One way for a health system to save money is for patients waiting for elective surgery to be reviewed by a second surgeon. A study in New York found that when 5601 patients were sent for second opinions 490 procedures were rated as not medically necessary (Journal of the American College of Surgeons 1997;185:451-6). Twenty five years earlier a similar study had found twice as many planned operations unnecessary, but even the current rate of 9% makes the exercise cost effective.

Ischaemic renal disease is defined as a clinically important reduction in glomerular filtration rate or loss of renal parenchyma caused by haemodynamically significant renal artery stenosis. A review in the Journal of Hypertension (1997;15:1365-77) claims that the condition is the cause of between 11% and 14% of all cases of end stage renal failure and that clinicians should look harder for this potentially reversible cause.

Around one quarter of all Americans believe they have a food allergy, but the true prevalence is much lower. A review in JAMA (1997;278:1888-94) says that possibly as many as 6% of infants experience allergic reactions to foods such as cows' milk, but among adults the prevalence of food allergy is only 1.5%, with a further 0.1% being allergic to some food additives.

Few patients found to have small cell lung cancer survive free of the disease for as long as two years, but researchers in the United States collected 611 who had done so (Journal of the National Cancer Institute 1997;89:1782-8). Follow up showed that 87 had developed second cancers, mostly squamous cell lung cancers. The risk was higher in those who had had radiotherapy to the chest and was doubled in those who had continued to smoke.

In 1583 Georg Bartisch, who was oculist and cutter for bladder stones to the Duke of Saxony, published a textbook of ophthalmology, described in the Australian and New Zealand Journal of Ophthalmology (1997;28:295-8). Most illnesses, he said, were punishments for sin, but the more serious ones he attributed to witchcraft. Nevertheless, he offered some practical treatments for squints, emphasising the importance of early intervention.

A woman aged 31 had epidural anaesthesia during labour. The epidural space was easily cannulated at the level of L3-4, and a total of 11 ml of 0.25% bupivacaine was given with the patient in the left lateral position. Thirty minutes later an epidural infusion regimen was started with 0.08% bupivacaine and fentanyl. One and a half hours later she complained of a strange feeling in her left eye and was found to have signs of Horner's syndrome—ptosis, small pupil, and congested conjunctiva. She was able to give a good cough and move all her limbs, and there was no motor weakness. The epidural infusion was stopped, and the eye signs disappeared after 90 minutes, when the infusion was resumed.

Henry Paw, specialist registrar, department of anaesthetics, James Paget Hospital, Great Yarmouth NR31 6LA

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A thought provoking comment on bacterial vaginosis appears in Developmental Medicine and Child Neurology (1997;39:836-40). Prenatal or even preconceptional infection might, the hypothesis suggests, lead to intrauterine infection. This increases the risk of damage to the white matter in newborn infants, which is an important cause of cerebral palsy. If this theory is correct then aggressive treatment of bacterial vaginosis in women of childbearing age might reduce the numbers of infants being born with cerebral palsy.