BMJ  2004;328:1024 (24 April), doi:10.1136/bmj.328.7446.1024

Minerva

Childhood vaccination has been blamed for a long list of disorders. One possible example is type 1 diabetes mellitus, which has become more common in developed countries which have also been urged to adopt an ever growing number of vaccines for use in children. Now the New England Journal of Medicine ( 2004;350: 1398-404)[Abstract/Free Full Text] has published the results of a vast study in Denmark of 681 children with 4,720,517 person years of follow up and found no link between diabetes and childhood vaccination.

Up to a third of patients with fibromyalgia are eventually diagnosed as having irritable bowel syndrome as well. The connection is strengthened by a finding of abnormal results on the lactulose breath test in both groups ( Annals of the Rheumatic Diseases 2004;63: 450-2[Abstract/Free Full Text]). The practical value of these findings is that the bowel symptoms can be relieved by treatment with antibiotics to eliminate the overgrowth of bacteria in the intestines.

Should someone who has just been found to have a primary infection with HIV be treated with highly active antiretroviral therapy (HARRT)? This seems likely to be a valuable treatment, but a review in AIDS ( 2004;18: 709-18)[CrossRef][ISI][Medline] concludes that there is no clear evidence that patients with access to acute antiretroviral therapy have any benefit from its immediate introduction. What is needed (surprise, surprise) is a randomised controlled trial of early short term HAARTS.

Colorectal cancer is the second leading cause of death related to cancer in the United States. Only 10% of patients with this type of cancer are diagnosed before the age of 55 ( American Journal of Surgery 2004:187: 343-8[CrossRef][ISI][Medline]), and colorectal cancer in young patients seems more aggressive, presents later, and has poor pathology findings. Yet young patients diagnosed early (Dukes's stage A or B) have a better overall survival than older ones. The message is that clinicians need to be aware that this cancer can affect young people and that when diagnosed early this is a cancer with good results available.

Carbon monoxide is undetectable by the human senses: it is colourless, odourless, and tasteless. Poisoning by the gas kills around 50 people a year in Britain. Less intense exposure can mimic influenza or gastroenteritis or cause non-specific symptoms such as headache. A review in Age and Ageing ( 2004;33: 105-9)[Abstract/Free Full Text] acknowledges that the place of treatment with hyperbaric oxygen remains uncertain, but it seems likely to be useful in patients who have a carboxyhaemoglobin concentration of over 20% and one or more of loss of consciousness, neurological features other than headache, myocardial ischaemia, or pregnancy.

Meningiomas make up a fifth of primary intracranial tumours, but many are asymptomatic. A study in Vienna recruited 532 women aged 75 who agreed to have magnetic resonance imaging of their heads and were also examined by a neuropsychiatrist ( Cancer 2004;100: 1208-12[CrossRef][ISI][Medline]). Nine of the 318 who completed the study were found to have meningiomas, but they chose not to be treated: at the age of 75, symptomless meningiomas are not an obligatory indication for surgery.

Severe acute respiratory syndrome (SARS) is caused by a novel coronavirus, which has been consistently isolated from patients with the disorder. SARS is regarded as a type of pneumonia, but detailed examination of the records of the 142 patients with SARS treated in Hong Kong found that 69 had developed diarrhoea, which was probably due to the virus having been swallowed ( Clinical Infectious Diseases 2004;38: 467-75[CrossRef][ISI][Medline]). The authors say that the nasopharynx and the intestines react differently to invasion by the virus.

Ageing is associated with several changes in the structure of blood vessels; these include thickening of the vessel walls, a decrease in compliance, and a wider pulse pressure. Ultrasonic examination of the vessels can provide quantitative data in the form of integrated backscatter analysis (IBS), which gives a useful assessment of the health of the vessels. A study from Italy ( Journal of Internal Medicine 2004;255: 52-8[CrossRef][ISI][Medline]) has now shown that this analysis gives a picture of the decline of the blood vessels with age and the slowing of these changes with regular aerobic exercise.

Minerva likes salami, which weighs little and takes up little space when she is packing for a walk. So she was upset to read about an outbreak of bloody diarrhoea in British Columbia which was traced to infection of some salami by E coli O157:H7. The manufacturing process was thought to be satisfactory ( Epidemiology and Infection 2004;132: 283-9[CrossRef][Medline]), so the public health experts concluded that it needed modification—probably a heat process should be found that would reduce the density of the pathogens.

Vibrio vulnificus is a Gram negative motile bacillus that flourishes in warm sea water. It may cause gastroenteritis, wound infections, or septicaemia in humans, and these infections may be fatal; in some series the fatality rate was as high as 75% ( Southern Medical Journal 2004;97: 163-7[ISI][Medline]). The vibrio grows rapidly in warm sea water and contaminates oysters, mussels, and other filter feeding organisms. Eating raw seafood and exposing wounds to sea water are common modes of infection in the Gulf of Mexico.

View larger version (270K): [in this window] [in a new window]   A 62 year old previously well man presented with backache over a period of two weeks. Pain was associated with parasthesia up to the ankle on the left side. He had had longstanding back pain and insulin dependent diabetes. On examination, the patient was afebrile, and local examination showed tenderness and spasm and sensory blunting from L3 to L5 dermatomes. The power in the toes was grade 3/5, and the ankle reflex was weak. Laboratory testing showed a raised white cell count, a C reactive protein concentration of 140 mg/l, and an erythrocyte sedimentation rate of 180 mm/hr. Magnetic resonance scans showed L2/L3 discitis with a paravertebral abscess. We carried out a decompression and gave the patient intravenous antibiotics for Staphylococcus aureus pyogenic discitis. P R Padala, senior house officer, J S Davies, consultant, department of orthopaedics, Worcestershire Royal Hospital, Worcester

Patients with primary biliary cirrhosis commonly complain of fatigue, which is often severe enough to impair quality of life. The pathogenesis of the fatigue is unknown, but there is growing evidence of some functional impairment of the globus pallidus associated with raised concentrations of heavy metals, manganese in particular. The impaired homoeostasis is evident long before there is any sign of hepatic encephalopathy.

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