Visual field constriction in a 42 year old woman MINERVA Try the picture quiz in Send comments or suggest ideas to Minerva: [email protected] ENDGAMES, p 38

“Fret not with that impatient hoof, snuff not coming of a new range of powerful drugs the breezy wind” is an immortal line from working on specific inflammatory pathways Caroline Norton’s poem “The Arab’s Farewell coincided with evidence that early aggressive to His Steed” (circa 1850). The steed the intervention could prevent progression, and Arab was parting from here was his horse, modern rheumatologists are now kept busy but it is possible that Arabs may have to deciding on what agent to use when. New is not bid farewell to their camels too if they are always better: a randomised trial in the Annals shown to be important vectors of Middle East of Rheumatic Disease (2013, doi:10.1136/ respiratory syndrome coronavirus (MERS- annrheumdis-2013-203440) showed that in CoV). The investigation, reported in Lancet newly diagnosed rheumatoid arthritis without Infectious Diseases (2013, doi:10.1016/ previous disease modifying treatment, initial S1473-3099(13)70164-6), found neutralising treatment with methotrexate and high dose antibodies to MERS-CoV in 100% of Omani methylprednisolone resulted in good disease dromedaries, but this is not definitive proof control with little structural damage. The drug that they are the main source of human combination was as effective as methotrexate infection. Besides, humans have had to put with infliximab. up with the risk of disease from camels for as long as they have kept them (possibly 4000 A patient, who had been admitted to intensive Sodium nitroprusside is a red salt that gathers years): these even toed ungulates can carry care after surgery, complained of the acute dust on the shelves of hospital pharmacies, brucellosis, trypanosomiasis, and a range onset of pain and paraesthesia in the first three enjoying the odd outing when a keen registrar of other transmissible parasites. And their digits of her left hand seconds after aspiration decides that someone is having a hypertensive impatient hooves have even snuffed some of of blood for gas analysis from a radial arterial crisis. It is a powerful nitric oxide donor—but their owners, although not very often (World catheter. Her nurse, who immediately noticed unfortunately donates cyanide at the same Journal of Surgery 2012, doi:10.1007/s00268- that air had been entrained in the tubing, time, so dosing needs care. Minerva was 012-1673-2). removed the line promptly. The patient’s astonished to read about a small (n=20), symptoms and signs resolved spontaneously double blind trial of sodium nitroprusside As Minerva remarked two weeks ago, everyone within a few minutes. for schizophrenia in JAMA Psychiatry (2013, now agrees that vitamin D is important for Antonio Albaladejo-Serrano, specialist in doi:10.1001/jamapsychiatry.2013.1292). more things than just bone. Currently, the anaesthetics, Department of Anaesthetics, Basingstoke A single intravenous dose produced relief of chest medicine literature is full of vitamin and North Hampshire Hospital, Basingstoke RG24 symptoms for up to four weeks. But when tiny 9NA, UK, Irene Faura-Núñez, consultant anaesthetist, D studies. In Thorax (2013, doi:10.1136/ Department of Anaesthetics, Hospital Santa Lucia, trials produce startling results, caution is the thoraxjnl-2013-203623), Dutch investigators Cartagena, Spain, Clara Morales-Muñoz, specialist watchword. report that rates of hospital admission for in anaesthetics, Department of Anaesthetics, Royal pneumonia are actually higher in people Hampshire County Hospital, Winchester, UK Minerva considers herself the patron goddess who take vitamin D supplements, but this Patient’s consent obtained. of librarians, and keeps a steady eye on their finding is likely to be due to confounding by Cite this as: BMJ 2013;347:f5237 welfare. Sequestered though they may be indication. In a small study in Allergy and within her temples of learning, their lives Asthma Proceedings (2013, doi:10.2500/ ideological rhetoric, fascinatingly explored by are not entirely without physical risk. A cross aap.2013.34.3656), improved persistence Roberta Bivins in Medical Humanities (2013, sectional study in Occupational Medicine of pneumococcal antibodies was seen in doi:10.1136/medhum-2013-010400). In the (2013, doi:10.1093/occmed/kqt080) found individuals with increased levels of vitamin 17th century, it was almost taken for granted that the seven day prevalence of self reported D. And a Danish population study in Thorax that children growing up under the grey skies pain in the neck and upper limb in female (2013, doi:10.1136/thoraxjnl-2013-203682) of England would get rickets, as described by librarians was 42% (95% confidence interval observed a novel association of lower plasma Daniel Whistler in his 1645 medical thesis, 33.7% to 50.5%). The annual prevalence was levels of 25-hydroxyvitamin D with faster De morbo puerili Anglorum [On the disease of 65% (56.6% to 72.8%). Unfortunately, the decline in lung function and an increased risk the children of the English], which he disputed investigator found insufficient evidence to of chronic obstructive pulmonary disease in successfully at Leyden. The children of Leyden confirm whether the prevalence was higher prospective analyses. no doubt grew up under similarly grey skies, than in the general population or among but were perhaps protected by a diet of herrings keyboard workers. But still, treat your female Rickets is, of course, the extreme manifestation and cheese. librarian with care. Help her by reaching for of vitamin D deficiency—a classic “disease those heavy, high shelved volumes yourself. Do of poverty.” When it was detected in British Minerva remembers the time when not tax her hands and eyes with endless, badly children throughout the 20th century, it rheumatology was a rather sleepy specialty framed literature searches. could trigger various kinds of indignant with a limited range of treatments. But the Cite this as: BMJ 2013;347:f5331

40 BMJ | 7 SEPTEMBER 2013 | VOLUME 347