MinervaBMJ 1998; 317 doi: https://doi.org/10.1136/bmj.317.7151.154 (Published 11 July 1998) Cite this as: BMJ 1998;317:154
Nicotine has comparatively mild psychoactive effects—in other words, it doesn't give much of a buzz—but research on rats has shown (Nature Medicine 1998;4:659-60) that it changes activity in the “brain reward” pathways in a manner indistinguishable from the actions of major drugs of abuse. So people who complain that giving up smoking is as difficult as giving up heroin or cocaine have science on their side.
It is a testament to the addictive properties of alcohol that alcoholic patients continue to drink even after the trauma of a liver transplant operation (Gut 1998;43:140-4). About half the patients in this British series admitted to regular drinking after receiving their transplant, many returning to drink within the year. The investigators were further worried by signs of liver damage in this group and have intensified their psychosocial support for patients as a result.
Vaccination against varicella (chickenpox) has since 1995 been recommended in the United States for all children aged 12-18 months, so deaths from this disease in infants are now seen as avoidable. Three deaths in children described in the Morbidity and Mortality Weekly Report (1998;47:365-8) are a reminder that as recently as the early 1990s this disease caused over 40 deaths each year.
A low protein diet slows the progress of chronic renal failure in at least some patients. A comparison of two low protein diets, one that used animal protein and one that used soya protein, found that they had similar effects in slowing the decline in renal function (Nephron 1998;79:173-80). Compliance was better with the vegetarian diet, so that patients taking it conformed more closely to the recommended intakes of energy, protein, and phosphate.
Recycling glass bottles has some less obvious advantages to society. For example, one third of 241 children questioned in inner city Philadelphia had cut themselves in the street at some time (Injury Prevention 1998;4:148-9). Most had cut their bare feet on glass, and a survey of the neighbourhood found that 30% of the walking area was dangerous because of broken glass.
Women having babies are a popular target for psychosocial research, but much less is written about their male partners. Over 7000 of these partners took part in the Avon longitudinal study of pregnancy and childhood (American Journal of Psychiatry 1998;155:818-23), which shows that factors associated with depression in women are also linked to depression in men. For example, men living in stepfamilies had higher rates of depression than men from more traditional families. Having a depressed partner also made depression more likely. Interestingly, the birth itself was not an important event in predicting psychological symptoms.
The US Public Health Service warns that HIV infection is currently the US's biggest threat. Changing people's sexual behaviour is difficult enough, but showing that it makes a difference to rates of sexually transmitted disease is even harder. In a randomised controlled trial seven sessions of training in risk reduction led to lower rates of unprotected sex and more consistent use of condoms but failed to improve overall rates of infection with sexually transmitted diseases (Science 1998;280:1889-94). Rates of gonorrhoea did go down, but only among subjects recruited from sexually transmitted disease clinics.
Any parents who have taken their precious baby for infant immunisations will be grateful for any progress towards a needle free experience. Immunising mice against diphtheria and tetanus by applying toxoid to the skin is a step in the right direction (Nature 1998;391:851), and phase 1 trials of bacterial enterotoxin patches are under way in humans. The ultimate goal (some way off) is to make immunisation as simple and painless as putting on a sticking plaster.
Media stories urging people to eat seashell concentrate to lose weight and stop taking the pill can frustrate the coolest of general practitioners. They will be encouraged by an articulate soapbox rant in the Medico Legal Journal (1998;1:31-3) arguing that, although journalists are hamstrung by deadlines and a limited grasp of the facts, there is hope if we all appeal to their sense of public duty. We should attack, says the author, the media culture that cares so little about misleading the public and continues to put topicality, simplicity, and excitement above accuracy.
Minerva has been encouraged recently by the increasing number of randomised controlled trials in surgical specialties. This month the Journal of Urology (1998;160:12-17) reports a five year follow up of over 500 men with benign prostatic hyperplasia randomised to surgery or “watchful waiting.” Those who had a transurethral resection did best, with rates of treatment failure of only 10%. A third of patients randomised to watchful waiting eventually had surgery. A commentator in the same journal suggests that surgeons can now give patients a clear guide to their risk of urinary retention if not operated on—about 2% a year.
Minerva sometimes dreams of a future utopia where surgery is a forgotten art and all ills are cured by magic bullets or invisible forces that leave no external wounds. Extracorporeal shock wave lithotripsy has that futuristic feel—shattering stones without harming living tissue—and is now being tested in people with calcific tendinitis of the shoulder (Journal of Rheumatology 1998;25:1161-3). Three women were pain free, with improved movement after just one session, and were asymptomatic after two years. After only three cases, however, the treatment is little more than a good idea. Controlled trials are the next step.