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Minerva: August 2000 Low tar cigarettes may entice health conscious smokers (if that's not an oxymoron), but it is doubtful whether they offer any health benefits over their regular counterparts. A review in the Lancet (2000;355:2159-61) points out that the tests that measure tar and nicotine are extremely sensitive to variations from the standard method: a machine taking a 2 second drag every 60 seconds to capture 35 ml of smoke. Cigarettes found to be low tar using this test can yield seven times more nicotine when smoked with 50 ml puffs every 30 seconds. Actually supplying condoms is a more effective way of ensuring they are used than is providing promotional information, according to the results of a randomised trial in Nicaragua. Housing shortages there mean that both commercial and non-commercial sex often takes place in low cost "moteles," which are supposed to provide free condoms, though the law is honoured more in the breach than the observance (Lancet 2000;355:2101-5). The trial design certainly sought to avoid the vagaries of self reported behaviour: one key variable was the result of the search for the used condom, by an investigator disguised as a cleaner. (See News Extra at bmj.com) Material gifts also have a part to play in the prevention of skin cancer (JAMA 2000;283:2955-60). Researchers posted bottles of powerful sunblock to the parents of white children, while control families got nothing. After three years, the children in the intervention group had significantly fewer acquired naevi than controls, suggesting they had successfully reduced their dose of solar radiation and, by implication, their later risk of skin cancer. Skin biopsy of a pigmented lesion is one of the commonest specimens that the jobbing histopathologist must face. The minutiae of pathological differential diagnosis (Journal of Clinical Pathology 2000;53:409-18) provide much to occupy the specialist, but probably the most important message that everyone needs to remember is to ensure that the age of the patient and the site of the lesion are on the request form: appearances and the probable diagnosis vary considerably according to the value of either variable. Male drivers lodged in congested traffic have new cause for misery. A French study shows that driving may reduce fertility by raising the testicular temperature by as much as 2.2°C more than in controls who walked (Human Reproduction 2000;15:1355). The finding helps to explain previous studies which found that occupational drivers take longer to conceive. Hypertrophic cardiomyopathy is a leading cause of sudden death in young adults, but assessment of this risk has until now been problematic. Apart from family history, the only recognised risk factors for sudden death are ventricular tachycardia or a previous cardiac arrest, which really means that the only reliable risk factor for sudden death is sudden death. Now a study of almost 500 such patients finds that using ultrasound measurement of the ventricular wall thickness provides a good index of the risk of sudden death (New England Journal of Medicine 2000;342:1778-85), identifying a group who may benefit from an implantable defibrillator. A whole profession, namely health visiting, has grown up based on the belief that interventions to improve parenting are effective, but there has been little formal evaluation in Britain. A systematic review (Archives of Disease in Childhood 2000;82:443-51) of studies designed to improve parenting suggests that home visits can improve both the quality of the home environment and of parenting, though doubts remain whether such interventions should be targeted at high risk children or applied across the whole population. The doctor-patient relationship is analogous to marriage, argues a paper in the Journal of Medical Ethics (2000;26:194-7). Something of the hope that two newlyweds must have in the future pervades the emotional tenor of each encounter, and the relationship must be consensual and negotiable and both parties should gain in the course of their encounters. The idea has at least one practical application: unwillingness to consider how things may go wrong in future may explain the low uptake of advance directives. More evidence, if any were needed, that the sympathomimetic drugs of recreation-cocaine, amphetamines, and ecstasy-are bad for the heart. A double blind study of cocaine against placebo shows that the drug enhances platelet aggregation and therefore the risk of thrombosis (Heart 2000;83:688-95), while an accompanying review catalogues an impressive list of side effects including hypertension, coronary artery spasm, and arrhythmias. Recent research has suggested that inflammation plays an important part in the pathogenesis of atherosclerosis. One example is a report in the European Heart Journal (2000;21:1000-8) of 1411 patients who survived an acute myocardial infarction. The severity of their coronary artery disease as assessed angiographically was strongly associated with the serum concentration of C reactive protein. What is still uncertain is whether the inflammation in atherosclerosis accelerates the process or is reparative. Whatever the effect of watching violence in Hollywood films, violence is hard to avoid in any genre. A frame by frame analysis of the entire output of Hollywood in 1994 (100 films) found only one film with no violent acts. Even "family entertainment" such as the Lion King had 97 violent actions. Such is drama, but further analysis revealed that six in every seven acts of violence in the movies are divorced from their consequences (Injury Prevention 2000;6:120-4), with action movies being the worst offenders.
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