Minerva

From BMJ USA 2002;November:642

Smokers and childless women are known to go through menopause at a younger age than other women. Evidence from a British birth cohort suggests that early life influences also play a part in ovarian aging. Women of low weight at age 2 years had an earlier menopause, and those who had been breastfed had a later menopause (Human Reproduction 2002;17:2474–2479).

Injury protection strategies can be divided into active and passive prevention measures (seatbelts are active, airbags are passive). A study of crash survivors and the type of restraints used found that belts are clearly superior to bags in preventing thoracic aorta injuries. Bags alone do not influence the incidence of thoracic aorta injuries in frontal collisions, whereas belts prevented them whether or not airbags were used (Journal of Trauma Injury, Infection, and Critical Care 2002;53:309–313).

Primo Levi was an Italian chemist who survived a Nazi concentration camp and went on to write about the human condition. A review of a book about him in the Lancet (2002;360:882) says that Levi's works should be commended to all medical students. His prose, says the reviewer, works “like an enzyme on the indigestible truths of the atrocities, breaking the detail down in order that those who were not witnesses would digest what happened and, hopefully, ensure that it is never repeated.”

Minerva has just been told of the three eternal rules of health systems of Uwe Reinhardt, professor of economics and public affairs at Princeton. All health services are currently undergoing reform; the last reform was a disaster; somebody somewhere is saying that the current reforms will be bad for patients. Sometimes he adds a fourth: health ministers must have been bad people in previous lives in order to be reincarnated as health ministers.

A reader who visited a private health clinic in London brought another interesting view of economics to Minerva's attention. The prices the clinic charges for various consultations caught his eye, and he wondered what health economists would make of them. A consultation with a doctor (duration not specified) costs $31. A half hour Indian head massage or ordinary massage costs $31. Aromatherapy and reflexology (both one hour) cost $62. Is this a reflection of how medical advice is currently valued in the market place?

Despite all the efforts made to get people who've had a heart attack to stick to the drug regimens they've started in the hospital, many don't. One large Scottish study found that only 7.7% of patients continued to take statins after their myocardial infarction. There's a definite penalty to pay for stopping: those who took statins had a significant reduction in their risk of a further infarct compared to those who stopped (Heart 2002;88:229–233).

Half of people who have a primary hemorrhagic stroke die within one month—but for those who survive and regain independence, the long term prognosis remains a bit of a mystery. One large study that attempts to shed light on the issue calculates an annual rate of recurrence, a vascular event, or vascular death of up to 5.9%. The risk doubled for those over the age of 65, and men were twice as likely to have vascular events as women (Neurology 2002;59:205–209).

In the United States between 1980 and 2000 infant mortality in white babies fell from 10.9 to 5.7 per 1000 live births while in black babies it fell from 22 to 14 per 1000 (Morbidity and Mortality Weekly Report 2002;51:589–592), so the gap between black and white babies has widened by 25%. Some of the causes are social (the demographic risk factors such as maternal age and income), but others are probably biological, such as the high mortality in black babies of very low birth weight.

Do antidepressants make symptoms of Parkinson's disease worse, or is symptom deterioration due to the natural course of the disease? In a comparison of people taking levodopa who subsequently started a selective serotonin reuptake inhibitor, a tricyclic antidepressant, or no antidepressant at all, those who started taking selective serotonin reuptake inhibitors needed a faster increase of their antiparkinsonian drug treatment (British Journal of Clinical Pharmacology 2002;54:168–170).

Worldwide, colorectal cancer is either the most common or the second most common cause of death from cancer; overall the five year survival is only 40% (British Journal of Surgery 2002;89:946–947). The review argues that the risk of local recurrence depends to a large extent on the skills and technique of the surgeon. Surgeons with a high rate of local recurrence (which varies from 3% to 32%) should consider trying to upgrade their skills under the guidance of a master surgeon, adding chemotherapy, or referring patients to a colleague who gets better results.

The dangers of having a naked flame and, in particular, of smoking, near an oxygen supply are usually fully explained to respiratory patients who must be treated with oxygen at home. The need to explain this to hospital inpatients may not be so obvious. A woman was admitted for investigation of her hemoptysis and was given oxygen via nasal cannula. The attention of the nursing staff was drawn to her persistent smoking by an explosion—the patient was discovered with her head leaning out of an open window. She held the remains of a cigarette and had extensive facial burning. The use of nasal cannulas may be potentially hazardous for smokers who forget that they are wearing them.

Daniel Lawes, specialist registrar, Rupan Banga, senior house officer, Martin Clifton, consultant, Department of Surgery, Princess Alexandra Hospital, Harlow CM20 1QX, UK

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The interaction between grapefruit juice or whole fruit and therapeutic drugs was first observed in 1989, but how many doctors know which drugs may be affected? A note in the Canadian Medical Association Journal (2002;167:279–280) lists more than 20 drugs that may react with the grapefruit. Furthermore, the extent of the altered bioavailability depends on genetic factors. No such reaction occurs with oranges.