Minerva

Whether a single head injury can cause Parkinson's disease has been debated for nearly 200 years. A case report in the Journal of Neurology, Neurosurgery, and Psychiatry (1999;66:380-5) shows how magnetic resonance imaging was able to identify infarction of the left caudate nucleus extending into the lentiform nucleus in a patient who had developed signs of Parkinson's disease within six weeks of a head injury in a traffic accident. So the answer seems to be that acute trauma may cause the disease, but this is very rare.

When should a patient with necrotising pancreatitis have surgery to remove the necrotic tissue? Only rarely, says a review in the British Journal of Surgery (1999;86:147-8). The risks of surgery outweigh the benefits if the necrotic tissue is sterile. If, however, fine needle aspiration shows that the tissue is infected, surgical debridement gives the best chance of saving the patient's life.

Radiologists at the Mayo Clinic are convinced that virtual colonoscopy is the coming technique for screening for colorectal cancer—though they accept that a lot more evaluation is needed (Gut 1999;44:301-5). The test uses a spiral computed tomographic scanner to acquire data that is processed offline to yield two dimensional and three dimensional images. The patient's colon has to be distended with gas or air, but the procedure takes less than two minutes and the exposure to radiation is about the same as for a barium enema. A prospective trial on 70 patients found that for lesions of 1 cm or larger the sensitivity was 75% and the specificity 90%.

Surely by now epidemiologists and nephrologists should have decided whether people should be advised to reduce their salt intake substantially? Yet the controversy rumbles on (Medical Journal of Australia 1999;170:174-8). Minerva found herself in agreement with the commentator who suggested that the realities of life dictate that few people can alter more than one or two lifestyle habits, and salt intake comes well after other more clearly defined risk factors.

When Minerva was young varicose veins were more common in women than in men. A survey in Edinburgh (Journal of Epidemiology and Public Health 1999;53:149-53) has now found that chronic venous insufficiency and mild varicose veins are more common in men (40%) than in women (32%). Possible explanations include changes in lifestyle and working practices, but the most likely may be the general tendency for women nowadays to have fewer children than in the past.

A study in Sweden of all the 5406 deaths between 1992 and 1994 due to suicide or suspected suicide found that only a fifth of the victims had been taking antidepressants (British Journal of Psychiatry 1999;174:259-65). Physicians sometimes worry about giving depressed patients drugs that can be taken in lethal overdose, but the results showed that in only 2% of the deaths in men and 8% of those in women had fatal doses of antidepressants been taken. The authors conclude that it is the disease and not the medication that accounts for most suicides.

Surgical closure of atrial septal defects gives excellent long term results, with a hospital mortality of less than 1%. Nevertheless, the current fashion is for the defects to be closed by inserting a device via a catheter, and a bewildering variety of devices is now available. A review of the choices in Heart (1999;81:227-8) concludes: “given that surgical repair is such a safe and effective procedure these newer techniques must be shown to have comparable outcomes to justify their continued use.” As ever, trials are needed to restrain surgical enthusiasm.

Political trends in the United States suggest that abortion may possibly be recriminalised at some time in the next few years. An article in the American Journal of Public Health (1999;89:199-203) uses data from the 1970s, when abortion was first made legal throughout the United States, to predict the consequences of a change in the law. The calculations suggest that as many as 440 000 extra births might occur each year.

An outbreak of infection with hepatitis A among homosexual men in Rotterdam was found to be associated with visits by men to “darkrooms” in clubs and saunas. These are dark areas where gay men can have sex with multiple casual partners. A case-control investigation (Communicable Disease and Public Health 1999;2:43-6) which identified the risk from darkrooms was unable to determine which sexual practices were responsible for transmission of the infection, but the data were consistent with contamination of the hands having a central role.

With so much media attention being focused on genetic modifications to food, scientists are ducking their heads behind the battlements. One example is a recent editorial in Annals of Internal Medicine (1999;130:233-4) commenting on some recent outbreaks of food poisoning in the United States that might have been prevented if irradiation had been used to pasteurise fruit. The food industry knows that this treatment is safe and effective, but it won't introduce it because of fears of “commercial terrorism” from activists opposed to any scientific interference with traditional food practices.

A 29 year old man presented with a painful tender skin tag on the ulnar side of his left ring finger, with distal anaesthesia. This condition developed after closure of a skin wound from a glass laceration 15 years earlier. Exploration showed that the skin tag was connected deeply to the distal end of the cut ulnar digital nerve, and an excisional neurectomy was performed proximally. Histology confirmed a polypoid neuroma arising from the digital nerve and extending into the dermis with overlying hyperkeratotic skin. Presumably, the digital nerve stump had been left protruding into the skin wound at the time of suturing, and the resultant neuroma had grown out through the scar. The hand is free of pain and functioning well a year later.

L A E Heylen, senior house officer, P Sylaidis, specialist registrar, A M Logan, consultant, department of plastic surgery, West Norwich Hospital, Norwich

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Clomiphene has been used for many years for treating infertility, but Minerva was unaware that the drug may have a teratogenic action in early pregnancy. Revue Prescrire (1999;19:40-1) suggests that women being prescribed clomiphene should have a pregnancy test before they start taking the drug: if a pregnant woman has been exposed to the drug the pregnancy should be monitored closely.

In this era of managed care in the United States women with uncomplicated cystitis are often given antibiotics without having their urine sent for bacteriological culture. The result, says a paper in JAMA (1999;281:736-8), has been a doubling in five years of the proportion of infections due to Escherichia coli resistant to trimethoprim and sulphamethoxazole.