Taking too many painkillers can lead to “medication overuse headaches.” A German study found that the average length of time of taking painkillers before these headaches start is shortest for the triptans (5-HT₁ agonists) (1.7 years), longer for ergots (2.7 years), and longest for ordinary painkillers (4.8 years). Triptans caused migraine-type headaches, whereas ordinary analgesics caused tension-type headaches .

Although acupuncture is rarely written about in books about evidence based medicine, one writer believes that it is unlikely that acupuncture would have been around for 2500 years if it was just quackery . New technology may help to unravel the mechanisms involved. Positron emission tomography and functional magnetic resonance imaging, for example, each allow a view of what happens to the central nervous system when acupuncture needles are applied, and acupuncture points can now be linked with specific brain cortices.

Successful breast feeding often depends on how long it takes for proper lactation to get started. Working on the hypothesis that delayed lactation may be linked to stress, researchers measured cortisol levels in a group of pregnant Guatemalan women during the first stage of labour and again after delivery. Not surprisingly, primiparous women had higher cortisol levels than multiparous women, and lactation started earlier among the multiparous women whatever the mode of delivery. Primiparous women who had emergency caesarean section experienced the greatest delay in lactation (Journal of Nutrition 2002;132:3055-60).

In acknowledging the low rate of breast feeding in the United Kingdom, the United Nations Committee on Child Rights has urged Britain to adopt the International Code for Marketing of Breast-milk Substitutes. The code calls for an advertising ban, which Britain has never quite got around to implementing. The United Kingdom has five years before it faces the committee again. If it fails to act on the recommendation, it will have to explain why.

A few years ago the hormone leptin was the talk of the obesity community. Now cardiologists are taking it up. Commenting on an intriguing study in , which describes how high leptin levels are associated with vascular stiffness in adolescents, one writer says that although a causal link has yet to be confirmed, it represents “yet another harbinger of the epidemic to come.” Today's widespread childhood obesity will give rise to an unwelcome epidemic of cardiovascular disease in the next generation.

Mirroring what we know about sex differences and communication in the non-medical world, a meta-analysis of medical literature concludes that women doctors engage in communication that relates to the larger life context of patients' conditions. In other words, women doctors have a more patient centred communication style. By contrast, doctors′ sex was not related to the task specific communication elements of care such as diagnosis, prognosis, and treatment .

Here's more food for thought on the use of nuchal translucency to pick up Down's syndrome (trisomy 21). In one Spanish study, over 11 000 women were given early second trimester nuchal translucency scans by eight experienced ultrasonographers. In the trisomy 21 selected group the detection rate was 92% and the specificity was 95%. The authors say no other single screening strategy can detect this proportion of affected pregnancies with such a low false positive rate. This certainly leaves the benefits of using additional markers in question .

Why does a young person surrounded by the multitude of contraceptive options available in the 21st century, and armed with the knowledge of the adverse consequences of unsafe sex, get pregnant? A commentator in draws on the 19th century poet and philanderer Lord Byron as part of his response. “The reading or non-reading a book,” he wrote, “will never keep down a single petticoat.”

The most serious long term complication after hernia repair is chronic pain; 3% of 5506 patients who had hernia surgery in Scotland reported three months later that they still had severe pain. Of these, about a quarter still had severe pain over two years later, and about half described the persistence of mild pain . Chronic groin pain after surgery is thought to derive from nerve injury, which may be more likely to occur with the use of non-absorbable materials.

“We are not programmed to die,” says a professor of gerontology “and nothing in the body is designed to bring about ageing.” It's our environment that has changed, not our bodies. Diet and exercise can enable our bodies to live longer; poor housing and transport and high levels of crime can lead to a rapid downward spiral in the health and lives of elderly people. Ageing, he says, presents a challenge to society and an opportunity for the pharmaceutical industry (Pharmaceutical Journal 2002;269:488).

Canada has too few family doctors. Much blame has been directed at miscalculated cuts in the numbers allowed to enrol at medical schools. But a more accurate picture of what's happening was reported in the newsletter of the Canadian Health Services Research Foundation (Links 2002;5:4). The factor that had the greatest impact was increases in the amount of time spent in postgraduate training—more doctors are entering hospital specialties, and training to become a general practitioner now takes twice as long.

Figure.

A 3 month old boy arrived at the emergency department with swelling of his left fourth toe and an apparent laceration of 24 hours′ duration (top). The family could offer no explanation for the findings. Careful examination of the toe showed a blond hair wrapped tightly around its base. Pseudoainhum was diagnosed, and the constricting band excised (bottom). Ainhum, and pseudoainhum are terms applied to constricting bands of fibrous connective tissue, which usually involve the dermis and subcutaneous layers of fingers and toes. Treatable causes of pseudoainhum include hairs, clothing, or even sutures.

D A Mariathas, consultant accident and emergency Broomfield Hospital, Chelmsford