Beware of strange black rats and other stories . . .

BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g1998 (Published 13 March 2014) Cite this as: BMJ 2014;348:g1998

Minerva looks forward to the coming Golden Age of medicine, where every decision will be shared with individual patients according to the likely benefits and harms of each treatment. But how can you possibly quantify those harms and benefits for individuals as opposed to the herd effects in randomised trials? A paper in the European Heart Journal (2014, doi:10.1093/eurheartj/ehu004) shows that estimates relating to cardiovascular outcomes can be refined considerably by looking at subgroup data from existing trials and meta-analyses. But much more work; better identification of outcomes that are important to patients; and, above all, the incorporation of prediction models into dialogue with patients will be needed before the Golden Age can happen.

The aim of treating opioid addiction can be either abstinence or maintenance. Trying to mix the two just creates confusion. This is nicely shown in a recent Cochrane review (Cochrane Database of Systematic Reviews 2014;2:CD002207, doi:10.1002/14651858.CD002207.pub4) that compared the effectiveness of buprenorphine with placebo or methadone as maintenance therapy for opioid dependence. If you keep the daily dose of buprenorphine high—above 8 mg, and usually at 16 mg—it is better than placebo and as good as methadone for avoiding illicit opioid use. But start tinkering with the dose and its effectiveness becomes less than that of methadone and little better than placebo.

Degeneracy is rife among the youth of today. If you put healthy 17 year olds in a magnetic resonance scanner, two thirds of them will show degenerative changes in their cervical spine. Follow 60 of them up for five years, as in a study from Finland (Cephalalgia 2014, doi:10.1177/0333102414521509), and you will find that these “abnormalities” have no predictive value for neck or head pain.

Overall levels of bacterial, fungal, and mycobacterial meningitis in England and Wales remained stable between 2004 and 2011, according to a survey of cerebrospinal fluid samples in Lancet Infectious Diseases (2014, doi:10.1016/S1473-3099(13)70332-3). But although Neisseria meningitidis remains the bacterial frontrunner, at 22%, it is in slow decline, and Streptococcus pneumoniae is not far behind, at 18%. Meningitis due to group B streptococci in the first 3 months of life is becoming slightly more common, and so is meningitis due to Escherichia coli in adults aged 65 or more.

Minerva is impressed with the benefits most people with obstructive sleep apnoea report when they try continuous positive airways pressure (CPAP) by night. Clinic nurses exhort their patients that they must use the device every night and all night to get full benefit. For most people this is true, but a new study (European Respiratory Journal 2014, doi:10.1183/09031936.00180213) shows that in about a third of patients, CPAP can be discontinued for four nights without leading to a return of significant oxygen desaturation. Much beyond that, however, and the desaturation will return.

There is a large literature about dreams of dying but a smaller literature about the dreams that people experience before death. A study from the Center for Hospice and Palliative Care (Buffalo, New York) describes the dreams and visions of 63 dying patients (American Journal of Hospice and Palliative Care 2014, doi:10.1177/1049909113517291). Six categories emerged: comforting presence, preparing to go, watching or engaging with dead people they knew, loved ones waiting, distressing experiences, and unfinished business. Most of the dreams were comforting, and the authors of the study suggest that sharing all of them—good or bad—may be helpful to the dying.

The plague of Justinian may have been the most lethal pandemic ever seen in Europe. It arrived in AD 540 in Constantinople and gradually spread northwest, killing perhaps a third of the total population with a devastating illness often characterised by necrosis of the hands. Some historians think it may have helped to create modern England out of post-Roman Britain, by preferentially killing Celtic Britons who traded with the Mediterranean, rather than Saxon invaders who, by and large, kept to their autonomous farming colonies. We now know with reasonable certainty that it was a form of bubonic plague. In a new study (Lancet Infectious Diseases 2014, doi:10.1016/S1473-3099(13)70323-2), a novel branch of the Yersinia pestis phylogeny was detected in DNA extracted from two people in the early medieval Aschheim-Bajuwarenring cemetery in Bavaria. This Justinian branch is interleaved between two extant groups, 0.ANT1 and 0.ANT2, and is distant from strains associated with the Black Death and the minor pandemic of the 19th and 20th centuries. Nobody knows whether there are any rats in the world that still carry the curse of Justinian.


Cite this as: BMJ 2014;348:g1998

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