BMJ  2004;328:592 (6 March), doi:10.1136/bmj.328.7439.592

Minerva

From April 2004, patients in the United Kingdom will have access to all letters written about them by health professionals. Researchers recorded a range of responses when patients received a copy of the assessment letter that an adult psychiatry clinic sent to their general practitioners. Only two out of 76 patients found the letters unhelpful, and 83% said they wanted to continue receiving them. But in 17 cases psychiatrists said that, knowing a copy would be sent to the patient, they had omitted some of the information they would usually have included ( Psychiatric Bulletin 2004;28: 40-2[Abstract/Free Full Text]).

Patients admitted to Johns Hopkins Hospital, Baltimore, had their lung function assessed by an independent investigator. A quarter (26%) of 153 general medical patients were found to have airway obstruction. At discharge only 40% of the patients who had been identified as having obstructive lung disease were receiving bronchodilator medication. The report in Chest ( 2004;125: 106-11)[Abstract/Free Full Text] concludes that obstructive lung disease is common and is usually unrecognised and untreated.

Surgeons and gastroenterologists have for many years disputed which branch of the specialty can claim the best treatment for gastro-oesophageal reflux (known as GERD in North America). The rate of gastritis due to Helicobacter pylori is declining, but up to 40% of Americans have reflux, and it is becoming more common ( CMAJ 2004;170: 219-21[Free Full Text]). Choice of the optimum treatment is being complicated by the emergence of a stream of new techniques such as radiofrequency ablation and polymer augmentation of the lower oesophageal sphincter.

Animal research has indicated that early adverse experience results in altered glucocorticoid levels in adulthood, so psychologists measured (twice daily over 10 weeks) salivary cortisol in 87 people aged 13 years whose mothers had, or had not, had postnatal depression. Having a mother with postnatal depression was associated with higher, more variable morning cortisol levels, a pattern previously found to predict major depression. The authors say that their observations could provide a link between early events and later psychopathology ( Biological Psychiatry 2004;55: 376-81[CrossRef][ISI][Medline]).

It's not the cat's whiskers but rats' whiskers that have been helping scientists discover how nerve cell activity controls physical movement. By stimulating single neurones (which cause specific whisker movements) in the rat cortex, they've developed the delicate technique of linking brain activity with movement, which one day may help the development of prosthetic brain-computer interfaces—devices that convert "thoughts" into controlled movement ( Nature 2004;427: 704-10[CrossRef][Medline]).

The personality profiles of a sample of 313 UK doctors seem to differ significantly from the UK adult population norms, particularly on how people like to take in information and learn about things. This mismatch highlights the potential problem with communication between doctors and their patients, and one training point may be to enable doctors to adjust their consultation style when it might be appropriate to do so ( Medical Education 2004;38: 177-86[CrossRef][ISI][Medline]).

Minerva thinks it would great to find a sound way to prevent women who have quit smoking during pregnancy from restarting after they've given birth. One possibility is to encourage them to take bupropion, and there's now convincing evidence that although bupropion and its active metabolites are present in breast milk, the doses that would be ingested by breastfeeding infants are small ( Tobacco Control 2004;13: 52-6[Abstract/Free Full Text]).

We may be pushing towards more and more specific targets for cholesterol levels, but there's still a lot of debate about how best to achieve these targets within the limitations of healthcare resources, and indeed whether everyone should be aiming for the same target regardless of health status. Some are now questioning whether lipid lowering guidelines are quite as productive as has been generally supposed. Use of low dose statins, for example, may ultimately produce better results across populations as a whole ( Journal of the Royal Society of Medicine 2004;97: 66-71[Free Full Text]).

Another question of prevention overtreatment crops up in Blood ( 2004;103: 1527-33)[Abstract/Free Full Text]. In this case the debate is over the threat of invasive fungal infections in patients with haematological malignancies, especially in those undergoing allogeneic stem cell transplantation. A well conducted prophylactic trial of itraconazole versus fluconazole finds that intraconazole is more effective at preventing invasive aspergillosis, as long as patients tolerate it and the dosage is carefully monitored.

For those of us who are a little sceptical about the primary care access survey conducted by primary care trusts, which is supposed to reflect how easy it is to get appointments with GPs and nurses, it's reassuring to know that independent findings from MORI have confirmed that these surveys are a true reflection of GPs' availability (the other findings are still under scrutiny). The November survey showed that 93.7% of patients could be seen by a GP within two working days. The MORI poll came up with 93.3% ( GP Bulletin 2004;(27): 3).

Male circumcision is one of the most common surgical operations done worldwide and is considered by many to be a minor procedure. An estimated 647 million males (23% of the current world male population) have been circumcised for religious or other reasons. A 5 month old infant presented with a concealed penis after a routine circumcision had been performed for religious reasons at the age of 3 months. He had had normal genitalia and penile length before the operation. In this rare complication of excessive removal of the foreskin, healing and fibrosis cause the shaft of the penis to retract into the subcutaneous tissue. The condition needs surgical correction. M Yadav, consultant, P Sundaram, clinical fellow, department of paediatrics, Royal Bolton Hospital, Bolton BL4 0JR

Cardiovascular fitness is obviously good for the heart, but now two sets of experiments show that it's good for the brain, and why that might be so (www.pnas.org/cgi/doi/10.1073/pnas.0400266101). Increases in human cardiovascular fitness resulted in better cognitive functioning (especially concentration), illustrating that increased cardiovascular fitness can influence the plasticity of the ageing brain.

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Rapid Responses:

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GER vs GERD

Ernesto Guiraldes
bmj.com, 7 Mar 2004 [Full text]

A picture's worth

Mark S Horner
bmj.com, 11 Mar 2004 [Full text]