MinervaBMJ 1998; 316 doi: https://doi.org/10.1136/bmj.316.7144.1618 (Published 23 May 1998) Cite this as: BMJ 1998;316:1618
Medical termination of pregnancy using the antiprogestin mifepristone and a prostaglandin has been confirmed as a safe and effective alternative to surgery in a large multicentre trial from the US (New England Journal of Medicine 1998;228:1241-7). The success rate was shown to fall as the duration of the pregnancy went up: the best results were achieved in women who were less than 7 weeks pregnant. Unexpectedly, the medical regimen was less likely to work in women who had had previous elective abortions—more than half the 2121 women in this study.
With the advent of clot busting drugs for stroke, the pressure is on to get patients to hospital for treatment as fast as possible. Fast response depends initially on the patients recognising their symptoms and calling for help. A telephone survey in JAMA (1998;279:1288-92) reports, however, that people at risk are ignorant of the signs of impending stroke. Just over half of the 1880 people surveyed were able to list one of the five established warning signs. More mentioned “chest pain” as a warning sign than mentioned one sided weakness. Less than a third made any reference at all to weakness or numbness. Predictably, those at highest risk were the most ignorant.
The well established sociocultural divide between the United States and the United Kingdom extends even into the bedroom (American Journal of Public Health 1998;88:749-54). Americans have a greater dispersion of sexual behaviour than Britons and are also more opinionated about it; substantially more Americans than Britons reported unconditional opposition to extramarital sex, non-marital sex, and homosexuality. The authors conclude that the combination of the range of behaviours and strongly held beliefs makes it difficult to mount an effective campaign against sexually transmitted diseases and link their findings to high rates of these diseases in the US.
An editorial in the British Journal of Psychiatry (1998;172:373-5) argues that disgust is a forgotten emotion central to our daily lives. The authors describe elegantly the physical response to a disgusting stimulus: narrowing of the nostrils, raising of the upper lip, wrinkling of the brow, vocalisations (“yuk!”, “ugh!”), and a shudder. All are apparently absent at birth and develop between the ages of 2 and 3, which rings true with Minerva, who has removed woodlice, still kicking, from between the tonsils of a 1 year old member of her family.
Infection with Trichomonas vaginalis is the commonest sexually transmitted disease worldwide and has been linked to transmission of HIV. Most infection is asymptomatic, and control strategies are more likely to work if diagnostic tests are quick, simple, and acceptable. Researchers from Australia report that using the polymerase chain reaction to analyse samples from tampons is much more accurate than conventional detection techniques like high vaginal swab, endocervical swab, or a cervical smear (Sexually Transmitted Infections 1998;74:136-9). This is good news for women, who avoid an uncomfortable vaginal examination, and for public health campaigns; women can collect their own samples, however remote the setting.
Sugar rarely gets a plug in the BMJ, but we already know that it acts as a mild analgesic in term infants having heel pricks. Another randomised controlled trial has shown that it soothes babies distressed after immunisations (Archives of Diseases in Childhood 1998;78:453-6). One hundred and seven healthy babies attending for 2, 4, or 6 month immunisations were randomised to receive either 75% sucrose solution or water just before their injections. Distress scores and crying times were reduced in the sucrose group. The volume and sugar content of the solution was comparable with a dose of standard antipyretic syrup and unlikely to harm any fledgling dentition already present.
Eight cases of infants being infected with Salmonella senftenberg were investigated by the Communicable Disease Surveillance Centre (Epidemiology and Infection 1998;120:125-8). The somewhat surprising finding was an association between the illness and one brand of baby cereal. The manufacturers have made changes in the production process that should prevent any repetition of the outbreak.
The risk of someone acquiring HIV infection from a single episode of unprotected vaginal or anal sex with an infected individual is much the same as that from a needlestick injury. Experts disagree, however, about whether or not to offer postexposure treatment with antiretroviral drugs (Sexually Transmitted Infections 1998;74:144-8). The problem is the lack of any really conclusive evidence for the efficacy of such treatment after needlestick injuries. Setting up a trial to provide evidence of efficacy after sexual exposure is a daunting task, but the question needs to be answered.
Long term follow up of patients treated for cancer is widely perceived as valueless, but might patients discharged from an outpatient oncology clinic become anxious and make more calls on their family doctors? Apparently not. A report in the British Journal of General Practice (1998;48:1241-3) found that 41 patients discharged after 5 years of follow up made no more visits to the general practitioners afterwards than before, nor did they show evidence of anxiety or depression.
The detection rate for diabetic retinopathy can approach 100% with a “fail safe” system devised at the City Hospital NHS Trust in Birmingham, says a paper in the Journal of the Royal College of Physicians of London (1998;32:134-70). Patients are examined by an experienced optometrist using Polaroid retinal photography and ophthalmoscopy, both through dilated pupils, and this examination is backed up by the availability of an experienced diabetologist to discuss cases of uncertainty.
Patients with asthma treated in the long term with corticosteroids are likely to become seriously osteoporotic. A placebo controlled trial of 2 years' treatment with cyclical etidronate, calcium, and vitamin D (Thorax 1998;53:351-6) showed that the 22 patients in the treated group increased the bone density in their spines compared with those on placebo. An editorial (331–2) says that there is now enough evidence to justify a preventive strategy using either hormone replacement therapy for women past the menopause or biphosphonates.