Minerva

Minerva

BMJ 1998; 317 doi: https://doi.org/10.1136/bmj.317.7173.1668 (Published 12 December 1998) Cite this as: BMJ 1998;317:1668

Death rates from HIV infection have fallen sharply across Europe, according to data in the Lancet (1998;352:1725-30 Between 1995 and 1998 rates dropped from 23 to four deaths per 100 person years of follow up, a fall of more than 80%. The investigators attribute these dramatic results to new combinations of treatment, but they apply to only 2% of the world's HIV sufferers. The rest live and die outside Europe.

Observer bias can have a marked effect on the reported efficacy of a vaccine, conclude researchers in Pediatrics (1998;102:909-12). During a trial of pertussis vaccine they noticed a wide variation in the number of cases reported by doctors, and worried that underreporting of whooping cough would lead to an overestimate of the vaccine's efficacy. They urge investigators to give clear guidance on diagnosis in vaccine trials, as milder cases can easily be missed or ignored.

Polycystic ovary syndrome is a multisystem disease that means different things to different specialists. One commentator compares sufferers to the lost tribes of Israel wandering through the desert looking for a home (Fertility and Sterility 1998;70:811-2). What they need, he says, is a true generalist who will evaluate them properly, treat the system that is dysfunctional, and keep them under surveillance for long term complications like diabetes and atherosclerosis.

Teaching midwives about the evils of smoking in pregnancy failed to cut smoking rates among their patients in a non-randomised comparative trial (British Journal of Obstetrics and Gynaecology 1998;105:1171-6). About a fifth of the sample smoked in early pregnancy. Two percent of them managed to quit, but another 2% actually started smoking during the study. The “smoking aware” midwives made no impact at all on these dismal figures.

Complicated cancer surgery is best left to the experts according to data reported in JAMA (1998;280:1747-51). Death rates up to 30 days after surgery were lowest in the hospitals that treated most patients. The difference in performance was most marked for oesophageal surgery: death rates fell from 17.3% in the lowest volume hospitals to 3.4% in the highest volume hospitals.

Minerva was embarrassed again today by her sluggish recall of people's names. Perhaps there is something wrong with her left temporal cortex, where the wires for putting names to faces are located (Brain1998;121:2103-18). Investigators using functional brain imaging have traced face recognition, but not name recall, to the right lingual gyrus and both fusiform gyri. They did this by imaging volunteers' brains while they were looking at pictures of famous people.

Children from single parent families or families with step-parents tend to have more social, educational, and behavioural problems than their peers. Data from the Avon longitudinal study of pregnancy and childhood suggest that social and economic adversity faced by their carers is to blame (Journal of Child Psychology and Psychiatry 1998;39:1083-95). Poverty, poor housing, and a depressed parent (usually the mother) are, unsurprisingly, linked to problem children. Boys are more vulnerable than girls.

How should doctors get the clinical information they need? Browsing through journals is out because much of their content is irrelevant, the world wide web is chaotic and difficult to navigate, and colleagues are unreliable. CD Roms are the answer, according to one orthopaedic surgeon (Foot and Ankle International 1998;19:651-2). Six or seven of them and a second-hand laptop computer add up to an entire wall of library journals, he says, which can be searched with ease during coffee breaks.

Figure1

This 17 year old boy (left) presented to his general practitioner for the first time in 5 years because of minor illness. His doctor commented on his size and was told that he was much shorter than his non-identical twin brother (right). He had dry skin, coarse hair, typical hypothyroid facies, and a small firm goitre, but good general health and a good school record. Investigations showed no measurable serum thyroid hormone, a very high serum concentration of thyroid stimulating hormone (841 mU/l), high thyroid microsomal antibody titres, and a delay of 5 years in his bone age. A diagnosis of autoimmune thyroiditis was made, and he began treatment with thyroxine.

Dr C F Macdougall, specialist registrar, Dr T Cheetham, senior lecturer, department of paediatric endocrinology, Royal Victoria Infirmary, Newcastle upon Tyne, Dr M Craig, general practitioner, South Shields

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Have you ever, in an idle moment, tried to define scissors? Here is one definition from Annals of the Royal College of Surgeons of England (1998;80:422-32: “True scissors, from the French ciseaux, belong to the pivot forceps group of instruments, constructed of two separate, usually equal halves which articulate precisely with each other by means of a stable pivot or joint.” So now you know.

Tacrine hydrochloride probably slows down mental deterioration in patients with Alzheimer's disease but not enough to have an impact on their functional autonomy (JAMA 1998;280:1777-82). A meta-analysis of 12 trials including nearly 2000 patients showed that the cholinesterase inhibitor can help some people some of the time, but it is still unclear exactly who benefits most.

Total knee replacements used to be cemented in place, but surgeons have increasingly switched to more expensive, cement free implants. Investigators from Newcastle and Leicester began a randomised trial of the two implant varieties in 1987 and report that there is little, if anything, to choose between them (Journal of Bone and Joint Surgery 1998;80-B:971-5). Both were safe, reliable, relieved pain, and improved mobility over 5 years of follow up. Once again, more sophisticated technology does not necessarily mean a better life for patients.

High dose adrenaline improves the success rate of resuscitation from cardiac arrest but makes no difference to long term survival compared with standard dose adrenaline (New England Journal of Medicine 1998;339:1595-601). Researchers randomised 3327 patients who had collapsed outside hospital to repeated doses of 5 mg or 1 mg of adrenaline. More of the high dose group survived to hospital—about a quarter—but only about 2% in both groups survived to discharge.

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