BMJ 2004; 328 doi: https://doi.org/10.1136/bmj.328.7451.1326 (Published 27 May 2004) Cite this as: BMJ 2004;328:1326

Is rheumatoid arthritis a consequence of natural selection for enhanced tuberculosis resistance? A paper in this month's Medical Hypotheses (2004;62: 839-43) says the modern pattern of rheumatoid arthritis is similar to the pattern of tuberculosis 200 years ago. Populations that suffered severe epidemic tuberculosis now have the highest rates of rheumatoid arthritis. One theory is that the genes that increased resistance to tuberculosis infection ended upincreasing the risk of developing rheumatoid arthritis.

A definitive “dictionary of medicines and devices” has been introduced by the NHS (www.dmd.nhs.uk). The idea is that it should enable computer systems to exchange information about specific drugs and devices, thus reducing the chances of error.

A survey looking at some of the reasons why US providers of care don't provide highly active antiretroviral therapy (HAART) to medically eligible HIV infected drug users has identified specific barriers. Resistance to prescribing HAART included being a non-physician, working with populations with a high prevalence of mental illness, injection drug use, alcoholism and homelessness, and where patients had a limited ability to keep appointments. One solution might be to provide on-site drug treatment alongside mental health and social services (AIDS Care 2004;16: 485-500).

Sticking to a gluten-free diet can be pretty difficult and is possibly harder for children. Conventionally such diets have eliminated wheat, rye, barley, and oats. A randomised controlled study of giving oats to children with newly diagnosed coeliac disease shows that oats can be safely eaten in moderation without preventing clinical or small bowel mucosal healing (Gut 2004;53: 649-54).

The term neurodiversity refers to the variety of non-debilitating neurological behaviours andabilities exhibited by the human race. An article in the New York Times (9 May 2004) describes a new kind of disabilities movement which is based on the belief that there is no such thing as “normal” when it comes to the human mental landscape. It's a movement that wantstolerance for brain differences such as those found on the “autistic spectrum” of conditions (which cause behavioural quirks) as well as tolerance for the diagnoses themselves.

The formation of a single memory may involve thousands of changes in gene expression, neuroneformation, and nerve signalling. Using a technique called optical imaging to visualise changes in nerve connections when flies learn that a particular smell is associated with receiving a shock, scientists have captured the beginning of a complex chain of events that leads to the formation of lasting memories. It's the first time that optical imaging has been used to visualise a memory trace (Neuron 2004;42: 437-49).

The prevalence of fatigue in primary care patients ranges from 10% to 40% depending on the definition used. A prospective study of US medical students reported in the Journal of Hypertension (2004;22: 691-5) found that low blood pressure may be a risk factor for the later development of idiopathic chronic fatigue, especially in women. Hypotension was definedin this study as having a systolic blood pressure of under 110 mm Hg in men and under 100 mm Hg in women. Follow up took place at five or 10 years after graduation.

Minerva has often thought it would be safer and less fraught for patients with infections to be treated at home, rather than be admitted to hospital. In a randomised trial of home versus hospital administered intravenous antibiotics in adults, the former seemed to be well tolerated and was not associated with any major disadvantage to quality of life or clinical outcome. Home treatment cost about half that of hospital care (Journal of Infection 2004;48: 263-8).

Total body computed tomography as a form of health screening is attractive to lots of people, but it remains a thorny and emotive issue. While screening may lower mortality from an individual cancer, it may not necessarily lower overall mortality. Some patients will die from causes unrelated to the cancer that was detected and “cured,” and the anxiety produced by a false positive result poses a real and lasting threat to overall quality of life (British Journal of Radiology 2004;77: 370-1).

On a related topic, an ethicist writing in the Internal Medicine Journal (2004;34: 201-2) reminds readers that anyone who survives cancer becomes aware of the three elements of what has been called the “cancer survival state.” Firstly, the cancer label is an adhesive one: it sticks for life. Secondly, cancer leads people to develop a different relationship with their bodies: the body becomes a house of suspicion. Thirdly, survivors become aware of a separation from everyone, even those they love most.

Kitesurfing involves riding a small board over water while gaining propulsion from the wind by means of a large kite. It's a risky business, and the pattern of injuries sustained by kitesurfers is similar to that in contact sports. The most commonly injured sites among 235 kitesurferswho sustained 124 injuries over six months were foot and ankle (28%), skull (14%), chest (13%), and knee (13%). Over half the injuries occurred because the surfers were unable to detach the kite from their harness when they lost control of it (American Journal of Sports Medicine 2004;32: 921-7).

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Vitiligo is well known to occur at the site of minor trauma, the so called Koebner phenomenon. This 69 year old woman has severe chronic obstructive pulmonary disease with repeated hospital admissions for exacerbations. Treatment included oxygen and nebulised therapy via a facemask. This vitiligo was noted on her hospital admission. There is no evidence of vitiligo elsewhere nor of any other autoimmune disease.

Ali Mohammed, senior house officer, Martin Whitehead, specialist registrar, Evelyn Miller, consultant respiratory unit, Southern General Hospital, Glasgow, G51 4TF

Would you trade six months of healthy life to ensure better care in your final month? A US questionnaire has come up with some interesting results (www.cnn.com/2004/HEALTH/05/20/good.death.reut/index.html). It seems that high tech invasive intensive medicine is not everyone's cup of tea when the end isnigh. BMJ readers can register their vote about quantity versus quality this week on bmj.com.

Guidance at bmj.com/advice

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