BMJ  2004;328:176 (17 January), doi:10.1136/bmj.328.7432.176

Minerva

Computed tomography colonography—or virtual colonoscopy—is gaining ground as a minimally invasive technique for visualising the colon and screening for early neoplasms. Unfortunately, the images of the colon are accompanied by images of the other abdominal organs, bones, blood vessels, and soft tissues. These unwanted data may irritate the clinician, who has no choice but to consider other diagnoses. A study of 75 patients in Denmark ( Gut 2003;52: 1744-7[Abstract/Free Full Text]) found that 49 had extracolonic abnormalities and 12% needed further investigation. Two patients needed surgery.

Until 1997 the Mayo Clinic's procedure for ordering blood for transfusion used handwritten identification of the patient by the clinician in addition to the standard paperwork. The clinicians then asked for the system to be changed to eliminate the handwritten form ( Mayo Clinic Proceedings 2003;78: 1357-9). Within two years the risk of an error had risen from 1 per 10 000 to 6 per 10 000. The old system was reinstated, but not until 2001 did the error rate return to the old figure. The lesson, says the article, is to have an effective error identification system.

Scientists have successfully immunised mice against the Ebola virus. The vaccine involves virus-like particles made from Ebola's two coat proteins. These lack the genetic material needed for reproduction, so they're not infectious. They do, however, provoke an immune response, and when injected into these mice they induced cell mediated immunity via T cells and humoral immunity via B cells. All of the immunised mice were protected when exposed to the real virus ( Proceedings of the National Academy of Sciences 2003;100: 15889-94[Abstract/Free Full Text]).

Up to 48 commonly prescribed drugs could pose "unacceptable hazards" or simply be ineffective in elderly people. Because elderly people have slower metabolisms, chronic conditions, and weak constitutions, drugs that they might have tolerated a few years before could result in new side effects or unintentional overdoses, according to a report written by a panel of 12 geriatric psychiatrists, pharmacologists and other specialists (Washington Times 15 December 2003).

From drugs to alcohol: International Drinking Guidelines (a report from the International Center for Alcohol Policies covering 32 countries) says the guidelines on what constitute "safe" or "low risk" drinking levels differ widely. In the United States the "safe" range for men is 14-28 grams a day, whereas in France and New Zealand it's 60 grams a day. The range for women is even wider: it's 20 grams a day in Sweden, but 70 grams a day in Spain.

A high proportion of women with osteoarthritis of the hip also have low bone density. In a study of 68 postmenopausal women, 25% had occult osteoporosis, of whom 22% had vitamin D deficiency and 4% had raised parathyroid hormone. But of the osteoporotic women, just two had vitamin D deficiency, suggesting that vitamin D status is not correlated with bone density ( Journal of Bone and Joint Surgery 2003;85A; 2371-7).

It may be hard to believe, but football referees get dehydrated during matches. A study of 12 male Brazilian referees and assistants in the British Journal of Sports Medicine ( 2003;37: 502-6)[Abstract/Free Full Text] found that the total body water loss during a match was 1.6 litres, equivalent to 2.05% of body weight. Water intake during half time replaced only a quarter of the bodily fluids lost during the match. The assistants lost just 0.25% of their body weight.

The Los Angeles atherosclerosis study has identified a possible mechanism to explain the weak protective relation between dietary fibre intake and the risk of cardiovascular disease events. Researchers report a significant inverse association between the progression of the intimal thickness of the common carotid arteries and the intake of dietary fibre, especially pectin. One conclusion is that increased dietary fibre may be involved in the process of slowing the progression of atherosclerosis by regulating serum lipids ( American Journal of Clinical Nutrition 2003;78: 1085-91[Abstract/Free Full Text]).

The premise that the surgeon is "the captain of the ship" and must accept total responsibility for everything that occurs to a patient is vigorously challenged in the Journal of Thoracic and Cardiovascular Surgery ( 2003;126; 1259-60)[Free Full Text]. The very hierarchical structure we've created has led to a culture of blame within medicine. For as long as individuals assume responsibility, every medical error will be viewed as the fault of an individual, rather than a shortcoming of the system.

For those of you who watch what you eat and drink, and worry about heart disease, here is the truth—according to a joke currently doing the rounds. The Japanese eat very little fat, while people in Mexico eat lots. Both groups suffer fewer heart attacks than the British or Americans. Africans drink very little red wine, while the Italians drink large volumes of the stuff—but both these groups too have fewer heart attacks. An epidemiological conclusion might be that you should eat and drink what you like: speaking English seems to be what kills you.

A 67 year old man presented with lower urinary tract symptoms and many episodes of near-acute urinary retention, which he found, by trial and error, he avoided by standing on his head for 5-10 minutes each time his stream was cut off, finding then he was able to void again. X ray examination showed multiple bladder calculi, which undoubtedly obstructed his dependent bladder neck while he was standing but not while he was upside down. At open cystolithotomy more than 300 stones, weighing over 400 g, were removed. Alun Thomas, specialist registrar, F X Keeley, consultant urologist department of urology, Southmead Hospital, Bristol BS10 5NB

When is a gall bladder not a gall bladder? According to a study in Nature Genetics, when it's a pancreas (dx.doi.org/10.1038/ng1273). Researchers removed a developmental gene switch from experimental mice, and found that what would have developed into a gall bladder turned instead into tissues which worked remarkably liked a pancreas. The gene, called Hes1, is normally responsible for deciding which organ is which, and is common to mouse and man.

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Bladder stones

Hilary Richards
bmj.com, 21 Jan 2004 [Full text]