BMJ 2006; 333 doi: https://doi.org/10.1136/bmj.333.7572.814 (Published 12 October 2006) Cite this as: BMJ 2006;333:814

In the developed world, breastfed babies tend to grow more slowly than bottlefed babies. Whatever the reason, it isn't the falling concentration of zinc in breast milk that occurs during lactation. In a recent trial, growth velocities were no greater in babies randomised to receive zinc supplements than in unsupplemented babies (American Journal of Clinical Nutrition 2006;84: 594-601).

Twenty four hours after admission, the urine in the catheter bag of an elderly woman taken into hospital for pelvic fracture turned an intense purple colour. Puzzlingly, urine in the collecting tube proximal to the bag stayed its usual yellow colour. The explanation is that some urinary bacteria possess an enzyme able to convert a metabolite of tryptophan into a substance that interacts with the plastic of the urine bag to produce the pigments indirubin or indigo blue. Although dramatic, purple urine bag syndrome is harmless and disappears after treatment of the infection (Age and Ageing 2006;35: 542).

Patients with motor neurone disease often seek the help of physiotherapists, speech therapists, and other health professionals in an attempt to maintain independence for as long as possible. A recent systematic review is critical that so little has been done to measure whether the interventions they provide are of any benefit. But the authors acknowledge the ethical issues involved in withholding even unproven treatments in the face of such evident need (Neurorehabilitation and Neural Repair 2006;20: 424-34).

Doctors wearying of demands that they do more to tackle the growing problem of obesity might like to read a carefully considered appraisal of the likely benefits and harms of a screening programme for obesity in primary care. Its authors reckon that the evidence that screening would improve identification or that early intervention would improve outcomes is thin. What's more, most obese people are already trying to lose weight (Medical Care Research and Review 2006;63: 570-98).

After all the anxiety over the increased risk of myocardial infarction in people taking non-steroidal anti-inflammatory drugs it's a relief to learn that they are associated with unintended benefits too. In an American cohort study of nearly 2500 men, those reporting daily use of these drugs were much less likely to have symptoms of benign prostatic hyperplasia (American Journal of Epidemiology 2006;164: 760-8).

Every practising doctor encounters patients with physical symptoms for which no satisfactory medical explanation can be found. Trying to avoid overinvestigation, misdiagnosis, and inappropriate treatment—although usually in the patient's best interests—often leads to them becoming dissatisfied. Modern neuroimaging has identified regions of the brain that are implicated in, for example, functional pain syndromes, fatigue, and somatisation disorders. However, the specificity is low and the findings won't be of much help in management (Advances in Psychiatric Treatment 2006;12: 349-58).

Like everyone else, Minerva has been moved by the plight of people in Darfur. But she has to confess that her understanding of the historical and political causes of the conflict is less profound than it should be. The fighting has been spilling over the border into Chad, and reading an analysis of the politics of that country she was sad to learn that it too was in grave danger of regressing into outright civil war (African Affairs 2006;105: 443-9).

A study of people brought to the emergency room of a New York hospital with hypothermia found that many had an underlying infection. These patients were slower to re-warm and case fatality was higher than in people without infection. The message is that management of cases of hypothermia in an urban environment should emphasise detection and treatment of underlying illness (Academic Emergency Medicine 2006;13: 913-21).

It's well known that professional boxers are at high risk of both short term and long term neurological damage. But enthusiasts sometimes claim that the risk is negligible in the amateur branch of the sport because it's so well regulated. Measurements of neurofilament light protein and glial fibrillary acidic protein A in cerebrospinal fluid of 14 amateur boxers a few days after a fight should make them think again. These markers of neuronal and glial injury were substantially raised in the boxers after fighting compared with a non-boxing control group or with repeat measurements three months later (Archives of Neurology 2006;63: 1277-80).

Despite an embarrassing lack of evidence that peer review is an effective process, editors of medical journals seem unable to make decisions without it. Still, they can at least distinguish between good and bad reports from peer reviewers. A five point scale used for many years by editors of one journal to rate quality of reports has now been shown to be valid and reliable. Even better, the authors who wrote the papers reported upon agreed with the quality assessment (Obstetrics and Gynecology 2006;108:979-85).

Soft tissue infections in patients treated at a specialist clinic in San Francisco were almost always caused by Staphylococcus aureus and over half were methicillin resistant. A retrospective analysis found, perhaps unsurprisingly, that the antibiotics prescribed were often inappropriate. What is surprising however, is that cure rates were just as high in people prescribed an inappropriate antibiotic as in people prescribed one to which the infecting organism was sensitive. The authors wonder if antibiotics are necessary at all in these circumstances and suggest a randomised controlled trial (Archives of Surgery 2006;141:850-6 http://archsurg.ama-assn.org/cgi/content/full/141/9/850).

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A 46 year old man presented with a two month history of fever, weight loss, and a non-pruritic widespread maculopapular rash on his trunk, palms, and soles of his feet, typically seen in secondary syphilis. He also had mild splenomegaly confirmed by ultrasound. A treponemal plasma antigen test was positive at a titre of 1:1520. Antibodies to HIV were positive, he had an HIV viral load of 1 480 000 copies/ml, and his CD4 count was 400. The patient was treated with intramuscular penicillin and referred to the regional HIV unit. This case highlights the importance of HIV testing in anyone with a diagnosis of syphilis.

Gordon MacDonald (gm245{at}yahoo.co.uk), senior house officer, Lyndsey Nina Cook, foundation year 1 house officer, Vannamalar Selvaraasan, senior house officer, Simon Musgrave, consultant department of medicine, Trafford Healthcare NHS Trust, Manchester M41 5SL


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