Minerva
BMJ 1996; 313 doi: https://doi.org/10.1136/bmj.313.7059.762 (Published 21 September 1996) Cite this as: BMJ 1996;313:762
One third of all elective caesarean sections follow previous sections, but obstetricians in the United States are trying to persuade women to have a trial of labour rather than opt for a second section (New England Journal of Medicine 1996;335:689-95). A prospective study of 3249 women who chose a trial of labour and 2889 who chose a caesarean section found few major complications, but these were twice as common in the women having trials of labour as in those having sections. Two perinatal deaths were associated with rupture of the uterus.
The human papillomavirus most often associated with carcinoma of the cervix, human papillomavirus 16, was thought until recently to be transmitted almost exclusively by sexual contact. A review in the “British Journal of Obstetrics and Gynaecology” (1996;103:853-8) presents evidence that the virus may be acquired by an infant during its passage through the birth canal. As many as half of all pregnant women may have asymptomatic infection with human papillomavirus 16, and there is no consensus on what should be done, if anything, to prevent its transmission to the next generation.
Recent improvements in implantable blood pumps used as bridges to heart transplant operations have revived interest in the development of permanent mechanical cardiac supports (Heart 1996;76:200-6). The Jarvik 2000 provides a cardiac output of 10 l/min, takes the load off the left ventricle, and allows the diseased heart to continue to serve some useful purpose. Because no organ donor is required the device can be implanted before the onset of multisystem failure.
Metabolic studies made during the crossing of Antarctica in 1992 by Stroud and Fiennes are reported in the “British Journal of Nutrition” (1996;76:165-74). The two men towed their supplies on sledges to a height of 3500 m and consumed vast amounts of energy while each losing 20 kg in weight. Nevertheless, despite the loss of weight and the great exertion, protein synthesis was maintained.
The latest data on the epidemic of diphtheria in the newly independent states of the former Soviet Union (Morbidity and Mortality Weekly Report 1996;45:693-7) put the number of cases at 125 000 and the number of deaths at 4000. The message is clear: even after 30 years of apparent complete control of diphtheria the disease may emerge again if immunisation is not maintained.
Garlic is said to have many cardioprotective qualities, including the ability to lower the concentration of lipids in the blood. A controlled trial of the use of powdered garlic to treat hyperlipidaemia is reported in the “Journal of the Royal College of Physicians of London” (1996;30:329-34). After six months no differences were seen in the laboratory results of those patients taking garlic and those taking placebo—a contrast with earlier studies and a disappointment for believers in natural remedies.
When surgery is needed for a patient with a duodenal ulcer the operation most likely to be performed in Europe will be a highly selective vagotomy, but in North America surgeons continue to prefer truncal vagotomy (American Journal of Surgery 1996;172:9-12). Their justification is the risk of recurrence after the highly selective procedure, but recent studies have shown that this risk is lower than 5%. Surgeons in North America are also said to be more cautious about recommending operative treatment and so may treat patients with more advanced disease and more scarring, and they claim that truncal vagotomy is more suitable in these circumstances.
Primary pulmonary hypertension is a sinister condition, so any clues to its causation are important. A case-control study of 95 patients in Britain, France, Belgium, and the Netherlands is reported in the “New England Journal of Medicine” (1996;335:609-16). A clear history of the use of appetite suppressants of the fenfluramine type was obtained from 32% of the patients and 7% of the controls; for women who had used the drugs for more than three months the odds ratio was 23.
In addition to its actions on the reproductive system, oestrogen also affects the heart and blood vessels, the bones, and many other tissues. Studies of drugs that block the action of oestrogen have shown that these may vary in their effects from tissue to tissue (Science 1996;273:1171). Apparently the explanation for this variability lies in differences from one tissue to another in the molecular pathways that convey signals from a cell's oestrogen receptor to its genes. The hope is that further study of the variable oestrogen pathways may lead to the development of drugs that block only certain pathways while leaving others unaffected.
A primagravida aged 24 was found at 36 weeks to have a peculiarly shaped abdomen, with extreme ventral protrusion of the fundus of the uterus. The fetal head was engaged in the pelvis. Five days after admission a vaginal examination was done because of rupture of the membranes; the head was felt behind the posterior vaginal wall, and the cervix could not be reached. The diagnosis then became clear: this was a breech presentation with the head in the fundus incarcerated in retroflexion in the pelvis. This was confirmed at caesarean section. The child was in good condition and weighed 2650 g. The uterus was easily repositioned.—C N M RENCKENS, P P WILLIAMS, gynaecologists, Westfries Gasthuis, Postbus 600, 1620 AR Hoorn, Netherlands
Litigation against doctors is probably more common in the United States than anywhere else in the world, so Minerva was interested to learn that since 1977 no lawsuit has been successful against doctors who followed the standard programme of immunisation of children (American Family Physician 1996;54:185-96). On the other hand, parents have sued successfully for failure to immunise newborn infants against hepatitis B and for failure to immunise children against measles and Haemophilus influenzae type B.
Most people seem convinced that the helmets worn by child cyclists give them useful protection. Much of the research has been done in Australia, and the latest suggestion—reported in the “Medical Journal of Australia” (1996;165:249-51)—is that the design of helmets should be modified to give more protection to the face. An analysis of 813 children who had had accidents on their bicycles found that 321 had hurt their faces; most of the injuries were abrasions or lacerations, but the mouth and teeth were also often injured. Lightweight chin protection incorporated into the design of bicycle helmets would, says the report, prevent many of these injuries.