MinervaBMJ 1999; 319 doi: https://doi.org/10.1136/bmj.319.7209.586 (Published 28 August 1999) Cite this as: BMJ 1999;319:586
Venous thromboembolism is the leading cause of maternal death in Britain, and a review in the British Journal of Obstetrics and Gynaecology (1999;106:756-66) says that women with a family history of thromboembolism should be screened early in pregnancy for the known inherited types of thombophilia.
Reoperation is recommended for patients with persistent abnormalities after surgery for hyperparathyroidism, but a report from the Mayo Clinic (Archives of Surgery 1999;134:699-705) notes that the results of repeat operations have not improved in the past 20 years despite the introduction of sestamibi parathyroid subtraction scanning and intraoperative hormone monitoring. In 124 patients having repeat surgery at the clinic, the cure rate was only 88%—whereas it was 99.5% in patients having surgery for the first time.
In the current discussion of euthanasia one example from the past is Sigmund Freud, who endured 30 surgical procedures for his cancer of the mouth between 1923 and 1939. Early in the course of the illness he agreed with his personal physician that he would want help with dying (Archives of Internal Medicine 1999;159:1521-5). When Freud's suffering became intolerable he asked his doctor to remember their agreement; he went into a terminal coma after he was given a large dose of morphine repeated 12 hours later.
Premature ovarian failure (loss of ovarian function in women younger than 40) may be due to factors such as chemotherapy but is most often unexplained. Evidence is accumulating, however, that one cause is autoimmunity (Endocrinology 1999;140:3401-3). Other endocrine manifestations of autoimmunity may be found, such as Addison's disease. Research on animals suggests that the basis of the disease is a cell mediated autoimmune reaction caused by an alteration in T cell regulation.
Do patients with diabetes who have repeated episodes of hypoglycaemia have any evidence of brain damage? A reassuring answer has come from a reanalysis of the data from the nine year diabetes control and complications trial (Diabetes Care 1999;22:1273-7). Four cognitive factors were examined—spatial ability, processing speed, memory, and verbal ability. Those patients who had had five or more episodes of hypoglycaemia scored no differently from those who had had none.
Fish odour syndrome is an inborn error of metabolism that leads to the excretion of trimethylamine in the breath, sweat, saliva, urine, and vaginal secretions (Postgraduate Medical Journal 1999;75:451-2). Children with the disorder have problems of social isolation and low self esteem, but if the correct diagnosis is made much can be done to reduce the offensive odour by changes to the diet and the use of a special soap.
Both the skeletal and the respiratory muscles become weak in patients with chronic heart failure, and this heart failure related myopathy accounts for much of the low exercise tolerance in patients with this disorder (European Heart Journal 1999;20:1191-200). The gradual loss of muscle bulk could be prevented by a systematic programme of exercise training.
Between 1983 and 1995 a total of 82 patients with anorexia nervosa were compulsorily admitted to the eating disorders unit at the Maudsley and Royal Bethlem Hospitals in London. They formed 16% of the total admissions to the unit in that period. Comparison of the detained patients with 81 of the voluntary patients showed few differences—the exception was a higher rate of a history of childhood sexual or physical abuse among the detained patients (British Journal of Psychiatry 1999;175:147-53). In the short term the detained patients did well, gaining an average of 12 kg by discharge, but in the longer term 10 of them died, compared with two of the controls
Fifteen cases of intussusception have been reported to the Vaccine Adverse Event Reporting System as associated with the new rotavirus vaccine licensed in the United States in 1998 (Mortality and Morbidity Weekly Report 1999;48:577-81). Studies in California and Minnesota have suggested that the incidence is higher in vaccinated infants than in those not vaccinated, but at present the data are considered “inconclusive.” Nevertheless, parents of children given the vaccine are now being warned of the symptoms of intussusception.
Vaccination will probably eliminate meningococcal meningitis before we fully understand it, says an editorial in the Journal of Epidemiology and Community Health (1999;53:516). Advice on the control of outbreaks is based on slim evidence (which accounts for the variations from country to country in the treatment of contacts) Ideally, more controlled trials would be done, but studies which withheld treatment from some contacts would be unacceptable to the public.
Thirty million children in the developing world have heart disease due to rheumatic fever, and 70% of these will die prematurely at an average age of 35 (Tropical Doctor 1999;29:129-32). The condition is underdiagnosed and undertreated; wider use of secondary prophylaxis with penicillin could have a substantial impact by preventing the recurrences that lead to chronic valvular disease.
A 10 year follow up of patients enrolled in a trial of drug treatments for Parkinson's disease has added to the evidence that the mortality from the disease has hardly changed since the introduction of levodopa (Journal of Neurology, Neurosurgery, and Psychiatry 1999;67:300-7). Treatment brings undoubted improvement in the quality of life, but it does not slow the progression of the features unaffected by current drugs.