BMJ  2003;327:E66 (4 October), doi:10.1136/bmjusa.01090009 (published 5 September 2002)

BMJ USA: Minerva

Minerva

This article originally appeared in BMJ USA

A meta-analysis of randomised controlled trials comparing the efficacy of antihypertensive regimens with and without angiotensin converting enzyme (ACE) inhibitors showed that patients taking ACE inhibitors did better ( Annals of Internal Medicine 2001;135:73-87[Abstract/Free Full Text]). Data on 1860 non-diabetic patients followed for a mean of 2.2 years were analysed. The relative risk for end stage renal disease in the ACE inhibitor group was 0.69 (95% confidence interval 0.51 to 0.94). Those with proteinuria benefited most.

Minerva thinks that a diet of onions and black tea sounds dreadful. But 32 healthy humans participating in a randomised crossover trial were subjected to just such delights for the sake of science. Cancer and atherosclerosis may develop from oxidative damage to lipids, and onions and black tea are full of flavonoids, which are potent inhibitors of oxidative damage. Nutritionists hoping to detect changes in plasma markers of lipid peroxidation in people on a high flavonoid diet were sadly disappointed ( American Journal of Clinical Nutrition 2001;73:1040-1044[Abstract/Free Full Text]). The rest of us are probably relieved.

Hollywood has produced a vast number of films about mental illness. A review of the range of material in the June Medical Humanities (2001;27:26-29 points out that one rare diagnosis in particular takes a starring role: dissociative identity disorder. The Three Faces of Eve (1957) is considered the seminal film on this disorder, and the most recent example is Me, Myself and Irene (2000). Both films claim to depict schizophrenia, thereby contributing to the popularist notion that schizophrenia is about "split personalities."

Minerva is fascinated that she seems to wake up seconds before her alarm clock goes off, but she wishes she could be more alert. The natural "wake up call" is apparently controlled by the suprachiasmatic nucleus in the brain. Scientists have now identified a neuronal relay connection from this nucleus to the locus coeruleus, the part of the brain that controls alertness and arousal ( Nature Neuroscience 2001;4:732-738[CrossRef][ISI][Medline]). Minerva suspects that in her case, this relay system has been damaged.

At the end of the 13th century, surgical treatment for what today would be regarded as an indirect inguinal hernia was complicated and gruesome. After reducing the hernia the surgeon forced a heated cautery iron down through the skin (at the spot where the hernia had been visible) until the pubic bone stopped the cautery. An alternative was to apply corrosive medicines to the same spot over and over again, eating away the tissues until the pubic bone was reached ( Medical History 2001;45:319-340[ISI][Medline]). Today's mesh repairs sound infinitely more comfortable.

Treating sleep apnoea may save lives. More than 200 adults with sleep apnoea were treated with nasal continuous positive airways pressure for at least three years. Their motor vehicle collision records three years before and after treatment were compared with those of a similar number of control drivers. Untreated patients had had more recorded collisions than the controls, but after the treatment the rate in both groups became equal ( Thorax 2001;56:508-512[Abstract/Free Full Text]). One commentator estimates that treating 500 patients for three years could prevent 180 serious crashes.

Getting women to turn up for breast screening mammography remains an uphill struggle in many places. A review of community based recruitment strategies aimed at increasing attendance found that a single letter of invitation, a phone call, educational material sent by post, an invitation plus a phone call, and training activities plus reminders all boost uptake. Adding home visits made no difference. Including population based studies only increases the generalisability of these findings ( Evidence-Based Nursing 2001;4:87[Free Full Text]).

Using a condom is a real turn off for anyone with an allergy to latex. Reactions range from genital urticaria to anaphylaxis, although no cases of fatality have yet been recorded. An open study of a deproteinised latex condom produced by a French company found that among the 19 adults who took part, 17 had a positive skin reaction through a conventional condom, while none reacted to the deproteinised version ( Sex Transmitted Infections 2001;77:202-203[CrossRef]).

View larger version (109K): [in this window] [in a new window]   A 69 year old patient presented for arthroscopic knee surgery. Her husband, a doctor with severe Parkinson's disease, had been mistakenly resuscitated against his wishes and died three weeks later in the intensive care unit. After this event the patient had written a living will to ensure that no such confusion would occur in her case. A living will should be sufficient in making clear a patient's wishes, but in order to further clarify her instructions, she had also had the words "Do Not Resuscitate" tattooed on her left chest wall. The arthroscopy was completed without adverse event under regional anaesthesia. C McCartney, assistant professor, Glen McGuire, assistant professor, department of anesthesia and pain management, Toronto Western Hospital, Toronto, Canada M5T 2S8

A four year retrospective study of patients detained at Heathrow Airport and admitted to the hospital with severe mental illness has found that the rate of admissions was one per million passengers ( Psychiatric Bulletin 2001;25:261-264[Abstract/Free Full Text]). A fifth of these patients presented with "wandering." As Minerva has often found herself aimlessly wandering around the departure lounges of airports, she sincerely hopes that this clinical sign is defined as more than simply browsing around airport shops.

Drug permeability through skin is best tested by using human skin as a model membrane. Failing that, shed snakeskin is the next best thing because of its similarity to human stratum corneum. Investigating the possibility of topical delivery of ondansetron (an anti-emetic drug used by patients receiving chemotherapy), researchers observed that permeability from an aqueous suspension through snakeskin was very low. But pretreatment with oleic acid and alcohol enhanced skin penetration sufficiently to suggest that a topical formulation may be round the corner ( Journal of Pharmacy and Pharmacology 2001;53:789-794[CrossRef][ISI][Medline]).

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