Minerva

Drug eluting cardiac stents fail for different reasons and in different settings. More are expected to fail when used in complex lesions than in simple lesions, and each type of device will have different failure rates at different points along any one complexity scale. Head to head trial data from different countries in complex settings also show how differently two devices may perform. Future trials should examine why these differences exist, not just compare one device with another (Circulation 2006; 113: 2262-5).

Another discussion about drug eluting stents appears in the Journal of Thoracic and Cardiovascular Surgery (2006;131: 956-62). Coronary revascularisation that integrates stenting with minimally invasive surgical anastomosis is feasible and seems safe. A study that combined stents implanted to lesions in the non-left anterior descending coronary artery and anastomosis of the left internal thoracic artery to the left anterior descending coronary artery resulted in no complications in the first 90 days. At seven months no one required repeat coronary artery bypass grafting.

Crack cocaine use is a problem now in rural areas (Journal of Public Health 28 April 2006, doi;10.1093/pubmed/fd1010). A survey in one English rural county found that 31% of drug users in treatment services are moderately or severely dependent on crack cocaine, which was linked with severe benzodiazepine dependence and engaging in sex work. These people lead chaotic lives and need additional support to help them to avoid relapse.

Cutting red meat from your diet if you have type 2 diabetes with nephropathy not only reduces the amount of albumin leaking into your urine but also improves your fatty acid profile. In a crossover controlled trial, 17 people replaced the red meat in their diets with chicken and adopted a lactovegetarian low protein diet; the urinary albumin excretion rate was significantly reduced with both regimens (American Journal of Clinical Nutrition 2006;83: 1032-8).

In the NHS, “Choose and book” for appointments, practice based commissioning, and payment by results are just the start of a more business focused healthcare economy. But where's the evidence for these financial policies? Outcome assessment is part of what's needed; instead measures of activity and process (waiting times and numbers of patients treated) are recorded. What matters to patients is the effect these healthcare interventions have on their wellbeing and length of life (Journal of the Royal Society of Medicine 2006;99: 226-31).

Paediatricians like to remind anybody who will listen that children are not just small adults. Similarly, paediatricians are not just small physicians. But in designing clinical studies, any new approach to treating children which differs from an adult approach must be compared with the proved adult algorithm in a controlled randomised study says an editorial in Chest (2006;129: 1118-21). Only then will we learn if paediatricians and physicians must treat their patients differently.

Figure 1.

A man presented to the accident and emergency department with a swelling between his teeth in the upper jaw. He had had a tooth extracted “with problems” 10 months earlier. The previous night, and a further three times the following day, he had blown his nose—which prolapsed the maxillary sinus lining. The extraction of the tooth probably caused a communication into the sinus, and a fistula persisted. The swelling was deflated by aspiration and he was scheduled for its repair under general anaesthetic, but before then it healed spontaneously.

Kah-yeoh Chong (Kahchong2001@yahoo.co.uk), senior house officer, Sat Parmar, consultant, oral and maxillofacial surgery, University Hospitals, Birmingham, B29 6JD

Lamenting the difficulties of “medical marriages,” a writer in the Canadian Medical Association's journal (CMAJ 2006;174: 1449) says of doctors like her husband—a rural GP—that “the sense of loyalty and commitment that sent them down their career path in the first place leaves them torn between two groups of people who really do need them—their patients and their families.” Finding a balance, she writes, is particularly challenging for rural physicians.

A cure for haemophilia A may be on the horizon. Current treatment is regular injections of factor VIII, but 25% of patients develop inhibitors, which makes the condition much more expensive and difficult to treat. Now scientists have discovered that haematopoietic stem cell gene therapy with a viral vector expressing pig factor VIII cured haemophilia A in mice without inhibitors developing (Blood 2006;107: 3859-64).

Most investigations into the placebo effect assume that placebos are inert. But the sugar in “sugar pills” is not chemically inert, in the same way that the coating of pills and capsules is not inert. A discussion in Psychiatric Bulletin (2006;30: 185-8) says that the “inert” chemical in any placebo may be relevant to the condition under scrutiny, and shouldn't be dismissed. Similarly, just because someone responds to a placebo doesn't mean that the ailment for which they sought help was false.

One solution to the falling numbers of new scientists and engineers is to expose young children to science education in the hope that this will foster a lifelong interest and eventual career in these subjects. This idea is based on the fact that career aspirations from a young age play an important part in later choices (Science 2006;312: 1143-4). Minerva wonders if that's why so many children who are ill and “exposed” to medicine from a young age go on to become doctors.

Young women undergoing chemotherapy for breast cancer face the dilemma of infertility induced by the treatment, yet often don't have time to undergo ovarian stimulation before starting chemotherapy or are not referred for consideration of such procedures. Ovarian cryopreservation, with a view to future autotransplantation, is an option (albeit not proved), and it should be offered only as a last resort, say writers in The Oncologist (2006;11: 422-34).

Substances that mimic the effects of oestrogen and other endocrine disruptive chemicals in the environment have been linked to human health and disease, especially when exposure was in early life. Epigenetic mechanisms have been implicated. One consequence is that such chemicals may go on having an impact across generations of people by becoming incorporated into the genome and being subject to selection (Endocrinology 2006;147: S4-10).