BMJ 2006; 332 doi: https://doi.org/10.1136/bmj.332.7543.736 (Published 23 March 2006) Cite this as: BMJ 2006;332:736

Children who take antiepileptic drugs are prone to developing hyperhomocysteinaemia, and the risk goes up with multidrug regimens and duration of drug taking. The condition is present in about 15% of children taking antiepileptic drugs long term. A double blind trial of oral folic acid supplementation in children taking such drugs reports that folic acid successfully increased folate concentrations and normalised homocysteine concentrations (Epilepsia 2005;46: 1677-83).

A new entity is creeping into the medical literature—osteonecrosis of the mandible or maxilla associated with the use of new generation bisphosphonates (used to treat osteoporosis, metastatic bone disease, and Paget's disease). Most patients can be managed with simple surgical debridement and stopping the drug, but some require quite radical intervention (Laryngoscope 2006;116: 115-20). The authors suggest best practice includes dental assessments before starting bisphosphonate treatment and close monitoring of oral hygiene.

The single question that effectively identifies patients who don't think asthma is a chronic disease (and therefore don't manage it as one) is: “Do you think you have asthma all the time, or only when you are having symptoms?” Poor self management of asthma is associated with the “no symptoms, no asthma” belief, and, of 200 patients admitted with their asthma to one inner city hospital in New York, a whopping 53% expressed it (Chest 2006;129: 573-80).

Africa is leading the way in the campaign against measles. The number of global deaths from measles has halved over the past six years thanks to major vaccination initiatives, with sub-Saharan Africa having the highest burden of the disease but also achieving the largest reduction in deaths (60%). The Measles Initiative (http://www.measlesinitiative.org) launched in 2001 features prominently in this success story.

Taking statins before having planned cardiac surgery significantly reduced mortality and morbidity within the first 30 days after surgery (Journal of Thoracic and Cardiovascular Surgery 2006;131: 679-85). The type of statin doesn't seem to matter, nor the dose, and the postoperative benefits are not attributed to lower serum lipid concentrations. What does seem to be important is that patients are taking a statin regularly, but the optimal duration that confers protection hasn't yet been established.

Infusing autologous bone marrow cells into the coronary arteries of patients who have had heart attacks to enhance tissue regeneration is still in the experimental stages. A study in Circulation (2006;113: 1287-94) reports that, 18 months after the infusion, left ventricular systolic function was no longer significantly better than it was in the control group. However, there is some evidence that the treatment accelerated the recovery of left ventricular ejection fraction after acute myocardial infarction.

Shushaku Endo, one of the finest Japanese novelists of the 20th century, though relatively unknown in the West, fought a prolonged campaign against life threatening tuberculosis. However, his close encounter with the medical profession left him disappointed. According to a historical review in the Postgraduate Medical Journal (2006;82: 157-61), he said: “Doctor, priest and novelist can put out their hands and touch the soul.” But the doctors, he said, failed the challenge.

What will it take to get the general population fit enough to improve overall health? Innovation and starting early is critical. An editorial in the British Journal of Sports Medicine (2006;40: 189-90) describes how in Finland the fastest growing activity among schoolchildren is cheerleading, with both boys and girls practising complex dance routines for hours every week. It's fun and non-competitive (unlike cheerleading as practised in the US, where it seems to have become an extreme sport, with several catastrophic injuries each year).

An investigation into recurrent abdominal pain in children and whether they are taken to a doctor reports that it's not the severity of symptoms or degree of psychological distress that predicts consulting behaviour. Only maternal fears about the symptoms differentiated between consulters and non-consulters (Digestive Diseases and Sciences 2006;51: 192-201). The consulters also missed significantly more school than the non-consulters, regardless of the severity of their symptoms.

Gastro-oesophageal reflux disease (GORD) causes various symptoms, including pain and cough. A case study in the Annals of Allergy, Asthma & Immunology (2006;96: 373-5) presents what the authors say is the first evidence of human vocal cord dysfunction in association with GORD. To confirm the diagnosis, they used the Bernstein test, which involved an infusion of 0.1N hydrochloric acid into the oesophagus to provoke an acute vocal cord dysfunction that resolved when the pH was raised by isotonic sodium chloride infusion.

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A 62 year old man treated with temoporfin for advanced carcinoma of the tongue noticed a purpuric discoloration to his fingertips 24 hours after receiving photodynamic therapy. These two fingers had been used to measure oxygen saturation with a pulse oximeter, and they show burns due to light exposure from the oximeter probe. Temoporfin is a photosensitising agent used as a palliative treatment for head and neck cancer. It specifically destroys tumour cells and requires oxygen and laser light for activation. Its administration results in increased sensitivity to light for up to 15 days. Appropriate exposure precautions are necessary, and prolonged pulse oximetry should be avoided during this time if possible. Simon Davis, senior house officer (sd4166{at}hotmail.com), Shilpa Mathew, senior house officer, Jonathan Buckland, specialist registrar, Adel Resouly, consultant, ear, nose, and throat department, Queen Alexandra Hospital, Portsmouth PO6 3LY

A comparison during labour of patient controlled epidural analgesia (bupivacaine plus fentanyl or bupivacaine only) with intermittent bolus epidural analgesia (bupivacaine plus fentanyl) reports that, contrary to expectation, patient controlled analgesia produced less maternal satisfaction. The women who received intermittent boluses felt that they could influence labour more and were generally more satisfied. It seems that the professionals' view that patient controlled analgesia offers greater control is not borne out by patients' experience (Acta Obstetrica et Gynecologica Scandinavica 2006;85: 188-94).

Guidance at bmj.com/advice

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