Intended for healthcare professionals

Minerva

Minerva

BMJ 2001; 322 doi: https://doi.org/10.1136/bmj.322.7285.564 (Published 03 March 2001) Cite this as: BMJ 2001;322:564

Excess underarm sweating is distressing and may lead to social stigmatisation and problems from macerated skin—so sufferers will welcome the results of a large double blind trial on 145 patients in Germany (New England Journal of Medicine 2001;344:488-93) confirming earlier reports that intradermal injection of botulinum toxin dramatically reduces sweat production. The full benefit lasted for up to 24 weeks, but even as long as six months after the injection sweat production was only half that at baseline.

Most doctors believe that malignant disease and gallstones are the most common causes of jaundice, but a study on 121 patients in Wales (Gut 2001;48:409-13) found that although malignancy was the leading diagnosis, the next most frequent was septic shock, followed by cirrhosis. Doctors who were questioned put viral hepatitis high among the common causes, but in this study it accounted for only two cases. Patients with jaundice are still most often referred to surgeons, though in practice few require surgery.

Much of the increased mortality from heart disease in patients with diabetes seems to be due to a diabetic cardiomyopathy first described in 1972 but still unfamiliar to clinicians. A review in Heart (2001;85:247-8) says there are now “ample experimental, pathological, epidemiological and clinical data to support the existence of this cardiomyopathy.” It goes on to recommend that all patients with diabetes (in addition to metabolic control) require aggressive lowering of the blood pressure and treatment with an angiotensin converting enzyme inhibitor drug.

A detailed investigation of 320 children (mean age 10 years) with recurrent or chronic headaches found few differences between those diagnosed as having migraine without aura and those with tension headaches (Developmental Medicine and Child Neurology 2001;43:45-51). The authors question whether a distinction between the two types of headache is appropriate for the paediatric age group and suggest that the clinical forms probably overlap.

Some women find colposcopy very painful while others hardly notice it, according to a clinical trial testing topical benzocaine and ibuprofen against placebo (Obstetrics and Gynaecology 2001;97:5-10). Neither drug, alone or in combination, made any substantial difference to women's pain scores, though this was a small trial that might have missed small differences between the groups. Young women reported more pain during endocervical curettage than did older women, particularly if they reported pain during a speculum examination.

Minerva's long memory includes some of the many studies published during the past 40 years linking increased cardiovascular mortality and living in an environment with soft natural water supplies. This association has recently been identified in the Puy de Dome in France, where the water is very soft (Environmental Research 2000;54:219-27). Yet with all those years of research it remains unclear whether soft water is bad for us (perhaps because inorganic pollutants dissolve more easily) or hard water has some protective effect that is good for us.

British doctors who are bewildered and upset by recent attacks on their collective integrity may feel better after reading a comforting editorial in the International Journal of Clinical Practice (2001;55:3). Life, like rowing, moves forward while we can see only backward, it says. The temptation to look for someone to blame is therefore hard to resist. Doctors do not have all the answers. What they do have is an awesome responsibility that becomes unbearable when their best efforts to work within a cash starved and chaotic service are attacked as failures.

The draconic treatment for chronic pancreatitis is removal of the whole organ. This is likely to lead to diabetes, but that outcome may be prevented by autologous transplantation of islet tissue. A total of 222 cases have been reported to the International Islet Transplantation Registry (Digestive Surgery 2000;17:439-50) with around half the patients being independent of insulin. Nevertheless, says the journal, the benefit of total pancreatectomy and islet cell transplantation is still questionable.

Accident and emergency departments are familiar with the problems associated with removal (or attempted removal) of a constricting metal ring placed round the base of the penis. Help should be sought early from the fire brigade, says a report in the Annals of the Royal College of Surgeons of England (2001;83:49). Fire officers are skilled users of saws and grinders and know how to prevent the heat generated by their use from damaging the tissues of the penis.

Figure1

A 69 year old man with a non-small cell cancer of the lung presented with shortness of breath some months after chemotherapy. There was no evidence of a pleural effusion, either clinically or on a chest radiograph. A computed tomography scan of the chest, however, showed a large collection of fluid on the right side. A chest drain was inserted and drained 3 litres of fluid, which relieved his symptoms. A normal chest radiograph does not exclude a pleural effusion.

Adrian Blundell, senior house officer, D Fyfe, specialist registrar, PJ Woll, consultant, department of medical oncology, Nottingham City Hospital, Nottingham NG5 1PB

Multiple sclerosis was first seen in the Faroe Islands in 1943 and has since occurred there in four distinct epidemics. A review in the Journal of Clinical Epidemiology (2001;54:1-22) suggests that the source of the disease was the islands' occupation by thousands of British troops in the second world war. They postulate an infectious agent, but its nature is still unknown. The data suggest that most of those infected never go onto develop multiple sclerosis.

Neurologists treating multiple sclerosis need to rethink their management of the disease, says an editorial in Archives of Neurology (2001;58:30-1). Evidence from magnetic resonance imaging strongly suggests that cumulative structural lesions may occur during periods of clinical silence, and the journal advises that disease modifying therapies need to be used aggressively and proactively.

Fibromyalgia is said to affect one person in 50, most of them women. A review in the Canadian Medical Association Journal (2001;164:223-7) recommends treatments that include exercise, yoga, tai chi, sleep medications, and sometimes antidepressants. Investigations rarely help; even if a second musculoskeletal disorder is identified its treatment is unlikely to affect the symptoms of the fibromyalgia.

Footnotes

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