Minerva
BMJ 1998; 316 doi: https://doi.org/10.1136/bmj.316.7149.1992 (Published 27 June 1998) Cite this as: BMJ 1998;316:1992
The resurgence of tuberculosis in the United States in the late 1980s and early 1990s was associated with HIV infection and multiple drug resistance. It now seems to have been brought under control (Morbidity and Mortality Weekly Record 1998;47:253-7). The total number of cases reported in 1997 was 19 855, a drop of 7% from the total for 1996 and a 26% decrease from 1992. These results are thought to be due to stronger public health programmes and emphasis on getting patients to complete their treatment.
A randomised placebo controlled trial of fluoxetine and graded exercise for patients with the chronic fatigue syndrome (British Journal of Psychiatry 1998;172:485-90) found that the exercise programme produced improvements in functional work capacity and fatigue while the fluoxetine improved depression only. Only 71% of the 136 patients completed the trial: support and encouragement seem to be important factors in whatever treatment is given.
The costs to the community of back pain amount to 1.7% of the gross national product in the Netherlands—a startling statistic quoted in a review in Pain (1998;75:163-8). Health care accounts for only 7% of the costs, which are mostly due to compensation for time off work. Yet, says the review, multidimensional pain rehabilitation programmes are of proved value in getting people back to work. The key is early intervention in primary care with an emphasis on self care.
Apparently, primates rarely cause allergic asthma, but a man aged 36 who had worked for seven years in the zoo in Singapore developed asthma for the first time when he began looking after and displaying the orang-utans (Singapore Medical Journal 1998;39:127-8). When he was switched to looking after lions his symptoms improved. Rechallenge produced an immediate asthmatic reaction.
Minerva can recall a few patients with classic hallucinations and other symptoms of delirium tremens. This dangerous syndrome occurs in as many as 5% of patients with alcohol withdrawal problems and still has a mortality approaching 10%. A review in the Southern Medical Journal (1998;91:425-32) dismisses drainage of spinal fluid, hydrotherapy, insulin therapy, and electroconvulsive therapy as failed treatments. It recommends nothing very new: benzodiazepines, vitamins, and rehydration.
Radiation to the chest is known to induce breast cancer, but argument continues about the risk to women undergoing regular mammography. A computer simulation model (Journal of Medical Screening 1998;5:81-7) has now calculated that if screening is expanded to include women aged 40-49 one death from breast cancer induced by radiation may be expected to occur to save eight deaths from breast cancer. Assuming that the radiation induced cancers would be detected by the screening programme did not make any substantial difference to these calculations.
The Minerva illustration in the issue of 6 June of the use of old BMJs to make shopping bags pleased Dr D C Banks at the City Hospital in Nottingham, since he has for many years been sending used medical journals to Sri Lanka. He comments that it is nice to know that after they have been read they are used in other parts of the economy. He asks readers who have surplus journals published in the past two years to send them to Nottingham for passing on. The most pressing need is for specialist journals—there is no shortage of BMJs and Lancets.
The risk of a major stroke after a transient ischaemic attack is highest in the first three months after the onset of symptoms (Quarterly Journal of Medicine 1998;91:377-9). If the diagnosis is a thromboembolic complication of atheroma in the neck vessels the patient will need to be started on aspirin together with anticoagulants if there is atrial fibrillation. Surgical treatment will be needed for severe carotid stenosis To sort out these possibilities patients should be seen within two to three days at a fast track “one stop” clinic.
Asked to decide whether a result of a tuberculin skin test was positive or negative, 99 out of 107 doctors and nurses identified induration of 15 mm as negative when they should have reported it as positive (Chest 1998;113:1175-7). This test is over 100 years old, and its qualitative nature clearly causes problems. The authors suggest that further thought needs to be given to the definition of a positive result. Perhaps a more radical rethink is needed.
Mortality from coronary heart disease varies from state to state in the United States by as much as 40%. Telephone interviews with 681 000 men and women aged 45-74 (Preventive Medicine 1998;27:311-6) found that most of this variance was attributable to differences in the classic risk factors—smoking, overweight sloth, hypertension raised cholesterol diabetes mellitus and excess alcohol intake. Plainly, much of the variation could be reduced by basic changes in lifestyle.
A recent issue of Environmental Research (1998;77:167-78) published papers presented at an international conference on the human health effects of exposure to mercury held in the Faroe Islands. Mercury in fish seems to be a greater threat to health than mercury in dental amalgam, but the worrying thing is the evidence of subtle effects on the nervous system associated with exposures previously thought to be safe.
A man aged 34 presented with erythema and induration of the right areola; this was thought at first to be Paget's disease of the nipple. It became apparent from the history that the lesion was the result of repeated trauma while playing golf. A minor modification to his swing led to complete resolution of the irritant dermatitis. Sporting activities expose the skin to a wide variety of risks and golfer's nipple should be added to the list of better known disorders such as rower's rump and jogger's nipple.
Irshad Zaki, senior registrar, Eric Saihan, consultant dermatologist, University Hospital, Nottingham
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Thrombolytic treatment of acute myocardial infarction is successful within 90 minutes in around half of patients. The management of patients who show no electrocardiographic evidence of reperfusion is still uncertain (Postgraduate Medical Journal 1997;74:355-7). Salvage angioplasty should be considered if the facilities are available, but there is no research evidence to support repeat thrombolysis.
At least one quarter of men having a prostatectomy in Britain have presented with acute retention. Many are sent home with an indwelling catheter to await elective surgery. A massive audit of 1242 patients (British Journal of Urology 1998;81:712-20) showed that those having delayed surgery stayed fewer days in hospital but the results of the surgery showed no great differences. The implication, says the paper, is that the initial catheterisation could be done at home and admission could then be arranged later.
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