BMJ  2005;330:E361 (11 June), doi:10.1136/bmj.330.7504.E361

BMJ USA: Minerva

Minerva

Minerva

Women who undergo repeated abortions in Canada share a number of characteristics, apart from failure of contraception, or not using it. In a study reported in CMAJ ( 2005;172: 637-41)[Abstract/Free Full Text] a history of physical, sexual, or violence abuse is relatively common, as is a history of sexually transmitted disease, making the times when women present with an unwanted pregnancy a good opportunity to screen for violence and sexual abuse.

The short term benefits and safety of sirolimus-eluting coronary stents are well known. But now data are available, collected over three years in a multi-center trial of 238 patients randomized to receive either conventional stents or coated stents. Coated stents are associated with a sustained clinical benefit and low levels of major adverse cardiac events. The rate of adverse events at three years was 15.8% compared with 33.1% in patients assigned to conventional stents ( Circulation 2005;111: 1040-4[Abstract/Free Full Text]).

Another—but arguably higher risk—stenting strategy is more prone to problems. A study in the Journal of Thoracic and Cardiovascular Surgery ( 2005;129: 645-51)[Abstract/Free Full Text] analyzed four year follow-up data from patients with acute thoracic aortic rupture. Endovascular stent grafting was used in 32 patients and compared with conventional surgical treatment with cardiopulmonary bypass in 28 patients. Despite encouraging early outcomes, the stented group needed more intervention and experienced higher complication rates in the mid-term.

"Respectful Disposal" of the dead includes the thought that should go into where a postmortem incision is placed. The standard incision may pass from the base of the neck to the pelvis, but if it starts too high up, concealment may be impossible. Similarly, exposing the skull contents by cutting forward across the scalp can lead to needless distress. A pathologist writing in Pharos International (spring 2005, pages 44-45) suggests dispensing with tradition and starting the postmortem examination with the body face down.

The clot that proves to be the final straw and blocks a coronary artery, causing an acute myocardial infarction, may be days or weeks old. A histological analysis of blood clots removed during angioplasty within six hours after the onset of pain fell into three groups: "fresh" (less than a day old), "lytic thrombus" (1-5 days), and "organized thrombus" (more than 5 days old). In over half the patients examined, the clots were days or weeks old, confirming the suggestion that considerable time can elapse between plaque instability and the onset of symptoms ( Circulation 2005;111: 1160-5[Abstract/Free Full Text]).

When faced with having to make rapid estimations of weight without a pair of scales to hand—for example, before administering weight related doses of drugs—ask the patient to guess his or her own weight. A study involving 458 patients found that patients guessed most accurately (91% were within 10% of actual weight), whereas doctors and nurses consistently tended to underestimate the patients' weights ( Academic Emergency Medicine 2005;12: 262-6[Medline]).

Alendronate is widely used in the treatment of osteoporosis. It works by inhibiting bone resorption. But a report in the Journal of Clinical Endocrinology and Metabolism ( 2005;90: 1294-301)[Abstract/Free Full Text] suggests that you can have too much of a good thing. Of nine patients being treated with alendronate who sustained spontaneous non-spinal fractures, in six healing was delayed or absent for up to two years. Biopsies showed striking suppression of new bone formation.

Minerva has often wondered privately if the level of concern about the epidemic of obesity in children might not have reached the verge of hysteria. So she was pleased to see a thoughtful discussion of the potentially negative consequences of interventions to prevent obesity in Health Education Research ( 2005;20: 259-65)[Free Full Text]. Being the right weight is only one part of child health, yet it dominates current health promotion initiatives aimed at young people.

Polymyalgia rheumatica is common in late middle aged and elderly people, so it is surprising to discover that the syndrome was not defined or named until 1957. The diagnosis remains a matter of clinical judgment, and, beyond the raised erythrocyte sedimentation rate and rapid response to steroid treatment, there is no confirmatory test. All the criteria based diagnostic definitions that have been proposed have a high sensitivity, according to a recent comparison ( Annals of the Rheumatic Diseases 2005;64: 626-9[Abstract/Free Full Text]). Unfortunately, lack of information on how specific they are means that we still can't usefully judge which set of criteria performs best in practice.

View larger version (131K): [in this window] [in a new window]   A 58 year old man presented in the summer with fragility and blistering of the skin on the dorsum of his hands. He had taken nap oxen for four years for osteoporosis. Results of a blood, urine, and stool porphyrin screen and serum ferritin and liver function tests were within normal limits. When he stopped taking naproxen, the eruption cleared up. Naproxen may produce pseudoporphyria, which produces blistering on areas exposed to light, mimicking porphyria cutanea tarda. Other non-steroidal anti-inflammatory drugs, COX 2 inhibitors, diuretics, amiodarone, and nalidixic acid have also been implicated. Heavy exposure to ultraviolet A light can induce a similar picture—"sunbed pseudoporphyria." Abdul Hafejee specialist registrar abdulhafejee{at}hotmail.com Ian Coulson consultant department of dermatology Burnley General Hospital, Burnley BB10 2PQ, UK

A study of patients with fibromyalgia who were randomized into a group writing about traumatic experiences, a control writing group, or a usual care control group, found that the trauma writing group experienced significant reductions in pain and fatigue and improvements in their psychological wellbeing at four months in comparison to the control groups. But by 10 months the benefits had disappeared. The idea for the study came from the observation that people with fibromyalgia report high rates of past trauma, and that writing targets cognitive and emotional processing ( Psychosomatic Medicine 2005;67: 326-34[Abstract/Free Full Text]).

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