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Minerva Minerva was never able to detect ketones on a patient's breath, even when others recognised the characteristic smell from the end of the bed. A small sample of health workers who were tested on their odour discrimination also had trouble with acetone, often mistaking it for alcohol (Academic Emergency Medicine 2000;7:1168-9). It's equally difficult to distinguish wintergreen from camphor, although probably less clinically important. Participants' poor performance improved slightly on a retest, but only on uncommon smells. Australian surgeons performed 7887 lower limb amputations in people with diabetes between 1995 and 1998, an average of 13.97 per 100 000 total population (Medical Journal of Australia 2000;173:352-4). The national diabetes strategy aims to reduce these figures by half by the year 2005, partly by making sure that at least four fifths of people with diabetes get their feet looked at by a doctor once a year. Raccoons may be cute, but many of them carry raccoon roundworm, an ascarid that can infect children. One 11 month old boy was left severely brain damaged after raccoon roundworm encephalitis (www.pediatrics.org/cgi/content/full/106/4/e56). A close look in his back garden and an adjoining vacant lot revealed 21 raccoon toilet sites, all of which contained faecal material contaminated with eggs from Baylisascaris procyonis. Environmental officers cleaned up the mess and trapped many of the resident raccoons. A year later, however, they were back. Many women with premenstrual syndrome can be treated with behavioural, dietary, or lifestyle changes. A minority need something stronger, such as a selective serotonin reuptake inhibitor. A systematic review in the Lancet concludes that this type of antidepressant works nearly seven times better than placebo and relieves both physical and psychological symptoms of premenstrual syndrome (2000;356:1131-6). Women taking serotonin reuptake inhibitors had more side effects than women taking placebo, although the authors describe these side effects as "manageable" and suggest they can be controlled using intermittent dosing regimens. Poor growth makes children with chronic renal failure shorter than their peers, but they can catch up if treated with recombinant human growth hormone. Treatment during childhood can also improve final adult height. In one recent controlled study, most of the children given growth hormone became normal sized adults (New England Journal of Medicine 2000;343:923-30). Untreated children remained more than two standard deviations shorter than their peers. Children receiving long term dialysis were least likely to benefit. Well known seasonal variations in suicide rates-spring peaks for men, and spring and autumn peaks for women-may be disappearing (British Journal of Psychiatry 2000;177:366-9). A harmonic analysis of nearly 60 000 suicides in England and Wales shows that changing seasons now account for less than 17% of the variation in rates for both men and women. In the late 1960s, seasons explained nearly 50% of the year round variation in suicide rates. Hypertensive men and women who take thiazide diuretics have a third fewer fractures than controls. Could these cheap, safe drugs be an effective weapon against osteoporotic fractures in fit normotensive people? A randomised trial from the US stops short of measuring fracture rates, but shows that 25 mg a day of hydrochlorothiazide can preserve bone mineral density at the hip and spine in older men and women (Annals of Internal Medicine 2000;133:516-26). The benefits over three years were modest but could accumulate if treatment continues for 10 or 20 years, say the authors. It's often easier to know when to start drugs than when to stop them. How long, for example, should patients take angiotensin converting enzyme inhibitors after a myocardial infarction? An editorial in Heart reviews the evidence and concludes that for people with small infarcts and decent left ventricular function, six weeks is enough (2000;84:361-2). Treatment for one year is reasonable for higher risk patients, but indefinite treatment should be reserved for people who need ACE inhibitors for other reasons, including hypertension, heart failure, or diabetes with nephropathy. In the year between 1994 and 1995, 790 Americans contacted the Food and Drug Administration after reacting to Rio Hair Naturalizer System, a hair relaxing product (Archives of Dermatology 2000;136:1104-8). Most of them complained of substantial and disfiguring hair loss which took about eight months to regrow. A minority had no new growth more than two years after using the product-probably because it had a pH of 1.4 when mixed according to the instructions on the packet.(See Figure 1) In the middle of the last century, no one in Sweden lived more than 101 years. By 1990 the maximum age at death had increased to 108 years, and it continues to rise by just over a year every decade (Science 2000;289:2366-8). Demographers who analysed successive birth cohorts in Sweden from 1751 estimate that nearly three quarters of the increase is due to reductions in death rates above age 70. The rest they attribute to increased numbers of survivors to old age. There are 2394 practising doctors in Orange and Durham counties North Carolina. Between them, they successfully completed an estimated 53 million patient encounters in the 11 years between January 1989 and January 2000 (Western Journal of Medicine 2000;173:235-8). Remarkably, the local grievance committee received only 29 complaints from patients during that time. North Carolina's doctors may be good, but surely not that good. Patient relations committees, ombudsmen, and the offices of medical staff must have dealt with the rest.
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