BMJ  2004;328:E308 (12 June), doi:10.1136/bmj.328.7453.E308

BMJ USA: Minerva

Minerva

"Spaghetti syndrome" may become an entity of the past as wireless technology comes in from the cold. Gone will be the days of trailing lines, cables, and sensors around critical care beds. One serious concern is potential interference with medical devices, leading to compromised patient care, but this issue may have been overstated. Bluetooth, the short range radiofrequency link proposed as one of the remedies for spaghetti syndrome, has now been shown not to interfere with medical devices, and vice versa ( Anesthesia and Analgesia 2004;98: 566-567[Free Full Text]).

More sneaky maneuverings by the tobacco industry have been unearthed. An analysis of one airline's in-flight air quality study, conducted and sponsored by several tobacco industry companies in 1988, found that unfavorable findings were apparently deleted by industry scientists and lawyers before delivery to the airline. The study ignored the health implications of respirable suspended particles, promoting instead the industry's position that better ventilation could solve any problems posed by secondhand smoke ( Tobacco Control 2004;13[suppl 1]: 20-29).

Exercise is hailed victorious in a study that compared percutaneous coronary intervention, stenting, and a 12 month exercise regimen in 101 men with stable coronary artery disease. More of those who participated in the exercise program enjoyed an event-free survival and better exercise capacity at lower costs, mostly due to the reduced need for hospitalization and repeat revascularizations. To achieve the measured outcomes, $6956 was spent in the percutaneous coronary intervention group, compared with half that—$3429—in the exercise group ( Circulation 2004;109: 1371-1378[Abstract/Free Full Text]).

Here's another reason for breast feeding as long as possible. Prospective data from a cohort study have found that breast feeding is associated with a lowering of later blood pressure in children born at term. If the association is causal, breast feeding may become part of the overall public health strategy to prevent hypertension ( Circulation 2004;109: 1259-1266[Abstract/Free Full Text]).

Gone are the days when cutting the chest wall open was always necessary for cardiac surgery. The rapid evolution of keyhole surgery has seen mitral valve procedures performed without sternotomy, using a left sided posterior mini-thoracotomy approach. A case series of 40 published in the Journal of Thoracic and Cardiovascular Surgery ( 2004;127: 1026-1032)[Abstract/Free Full Text] indicates that this type of approach not only offers a valuable option in more complex cases but also has acceptable levels of perioperative morbidity and mortality.

Paraffin oil often fuels the lamps used by orthodox Jews during the Sabbath and other religious holidays. Unintentional pediatric exposure to paraffin oil is usually by ingestion, with the risk of aspiration. A two year study in New York found that 71% of the 45 cases occurred in orthodox Jewish children, and just 9% in non-Jewish children. Demographic data weren't available for the remaining 20%. Over half the incidents occurred within 10 hours after a religious celebration ( Pediatrics 2004;113: e377-e379[Abstract/Free Full Text]).

Caffeine consumption can put your blood pressure up acutely, but if you're drinking coffee on a daily basis, is this likely to be clinically significant? Individual differences in tolerance were investigated in a randomized controlled trial conducted over four weeks. Although raised systolic and diastolic response to the final caffeine challenge was completely lost in half the participants, the other half showed no loss of response, despite moderately high levels of daily intake beforehand ( Hypertension 2004;43: 760-765[Abstract/Free Full Text]).

Given that use of benzodiazepines is generally frowned on, it's curious that in mental health units benzodiazepines seem to be one of the flavors of the month for people with depression. An American survey found that over a third of inpatients with depression filled a prescription for a benzodiazepine, whereas 90% filled a prescription for an antidepressant. In contravention of most guidelines, inpatients received long term benzodiazepines; older patients tended to receive longer lasting supplies, but lower doses ( American Journal of Psychiatry 2004;161: 654-661[Abstract/Free Full Text]).

Minerva isn't religious, but she was struck by a discussion about using the Bible to teach the essentials of quality improvement ( Quality and Safety in Health Care 2004;13: 153-155[Abstract/Free Full Text]). The book of Daniel is apparently a good place to start. Hypothesis definition, interventions, control and experimental groups, potential sources of bias, and a final policy change based on evidence can all be found in the first 12 chapters. The authors conclude that Daniel deserves to be known as a hero of quality improvement, not just as a near martyr.

View larger version (101K): [in this window] [in a new window]   A 35 year old man presented with a four month history of an itchy, scaly rash confined to the palm of his right hand. The skin of his left hand was completely normal. He also had fungal infection of his toenails. Skin scrapings from the right hand confirmed the diagnosis of fungal infection with Trichophyton rubrum grown on culture. The rash cleared completely with a course of oral terbinafine. Fungal infection of the hand (tinea manuum) is usually asymmetrical and quite distinctive. The skin creases are filled with a fine powdery scale and the nails are usually involved. T rubrum is the commonest cause. Unilateral scaling of hands should always alert clinicians to the possibility of a fungal infection. Sarita Jain staff dermatologist Catherine Stephens consultant dermatologist Poole Hospital, Poole BH15 2JB, UK

The association between active and passive cigarette smoking and subarachnoid hemorrhage is strongly positive, especially in women. A population based case-control study concludes that the link is virtually eliminated within a few years of stopping smoking, even among heavy smokers ( Stroke 2004;35: 633-637[Abstract/Free Full Text]).

Pulsatile tinnitus is quite rare, but it should be swiftly investigated because in some people it may indicate the presence of a treatable condition. A series of 136 consecutive patients with confirmed cervicocephalic arterial dissection found that 16 (12%) presented with pulsatile tinnitus ( Journal of Laryngology and Otology 2004;118: 193-198[CrossRef][Medline]). The most common finding at angiography was irregular stenosis, most of which normalized during follow up. The authors say that a high index of suspicion and early angiography will avoid a delay in diagnosis.

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