BMJ  2004;329:468 (21 August), doi:10.1136/bmj.329.7463.468

Minerva

Half of all deaths in road crashes occur within one hour of the incidents, so it's clear that getting people out of wrecks quickly is critical. A Norwegian team has developed a "rapid extraction technique" based on reversing the forces of the original crash by anchoring the rear of the vehicle, and pulling the steering wheel and the front window pillars forward with chains. The time taken to get injured people out was significantly less than using standard techniques, and avoiding uncontrolled movements in the wreck was no more difficult ( Injury 2004;35: 739-45[CrossRef][ISI][Medline]).

A pregnant woman who had a preterm stillbirth was found to have had a severe Chlamydophila abortus infection, a disease carried by goats and sheep. It turned out that her husband was a goatherd, and he'd passed the infection to his wife. It mimics severe flu, and pregnant women living in rural areas should be made aware of this zoonotic risk ( European Journal of Clinical Microbiology and Infectious Diseases 2004;23: 487-90[Medline]).

Even though health professionals bang on about it, the message that patients with asthma should take their prescribed inhaled steroids throughout the year doesn't seem to get hammered home. A retrospective analysis in the Netherlands reports that 50% of patients used inhaled steroids for less than 200 days, and only 18% persisted for a year. Persistence rates went up with lower initial doses, or if the patient had a history of being admitted to hospital with a lung problem ( Respiratory Medicine 2004;98: 752-9[CrossRef][ISI][Medline]).

Minerva recalls talking to people about their perceptions of electroconvulsive therapy (ECT) and the trauma they assume it must bestow on those who receive it. But when the patients themselves are asked, a different story emerges. A survey conducted in one clinic found that while side effects were commonly reported, most people said that ECT had made them a little or a lot better. Fewer than 20% rated ECT as worse than going to the dentist ( Psychiatric Bulletin 2004;28: 289-91[Abstract/Free Full Text]).

Maggots were, in January this year, the first live animals to win approval from the Food and Drug Administration as "medical devices." They're being used to remove dead tissue that prevents healing. Recent studies have shown that surgical debridement of wounds, such as dodgy diabetic foot ulcers, removes about half the dead tissue, whereas maggots remove up to 80%. Despite their acceptance by the powers that be, there is still some reluctance to use them ( Las Vegas Sun 2 Aug 2004).

Working patterns and occupational demands over time indicate that patients with Alzheimer's disease had jobs with lower mental occupational demands and higher physical demands than did controls. The analysis of the study didn't throw up any differences in social or motor demands. What's not clear is whether the mental demands of jobs directly influence the neuropathology of the disease, or whether it's the influence of its early stages that determines whether or not people pursue mentally demanding jobs ( Neurology 2004;63: 498-503[Abstract/Free Full Text]).

Evidence is emerging that people with chronic fatigue syndrome may have a detectable immunological abnormality. People with chronic fatigue syndrome often report symptoms consistent with an underlying viral illness, and increased neutrophil apoptosis (programmed cell death) is found in patients with infection. A study of 47 patients with chronic fatigue syndrome found they had higher numbers of apoptotic neutrophils and lower numbers of viable neutrophils than did 34 healthy controls. The cases also had increased expression of the death receptor on their neutrophils ( Journal of Clinical Pathology 2004;57: 891-3[Abstract/Free Full Text]).

An American survey of 34 psychotherapists who had experienced the suicide of a client found that a third of them suffered severe distress, the most intense emotion being anger. Female therapists, and those with less than 15 years in practice, were more likely to have severe distress. Four factors were identified as critical to such distress: failure to hospitalise an imminently suicidal patient, a treatment decision felt to have contributed to the suicide, negative reactions by the therapist's institution, and the threat of a lawsuit by the family left behind ( American Journal of Psychiatry 2004;161: 1442-6[Abstract/Free Full Text]).

As the Olympic games move into week two, it's interesting to note that team spirit may play as much of a role as individual talent. A study of Swedish team gymnasts in the British Journal of Sports Medicine ( 2004;38: 398-401)[Abstract/Free Full Text] found that more than half (58%) of the 188 gymnasts competed despite having symptoms due to an injury on the day of the competition, and 55% reported recurrence of an injury at some time in their careers.

Non-smokers who get lung cancer are usually shocked at the diagnosis. The good news, though, is that people who have never smoked who develop adenocarcinoma of the lung have a better prognosis than those who currently smoke. The difference in survival rate may be related to the other conditions that smokers tend to have. Or it may indicate that the course of the disease in non-smokers is different because of differences in the mechanism that causes the cancer process in the first place, demographic factors, and behaviour of the tumour ( Chest 2004;126: 347-51[Abstract/Free Full Text]).

A paediatrician who spent much of the past seven years working overseas for aid agencies has returned to the NHS ( The Health Exchange 2004 August: 25-6). She's now working in public health and finds herself using her experience of working in feeding centres in famine areas to develop programmes around obesity. What aid agencies and the NHS have in common, she says, is managing resources properly and demonstrating the impact of the work on health outcomes to the funding bodies.

A 42 year old man presented with an enlarging, friable mass on the dorsal aspect of the right third toe, extending onto the foot. He was taking immunosuppressive drugs (tacrolimus, mycophenolate mofetil, and prednisolone) after a lung transplant. A squamous cell carcinoma was suspected, and biopsy showed granulomatous inflammation and abundant fungal organisms. Trichophyton mentagrophytes var interdigitale was cultured. The lesion resolved completely after surgical debulking and oral terbinafine. Organisms of relatively low pathogenicity can present in a highly atypical fashion in immunosuppressed patients. Susannah Hoey, specialist registrar, Keith Armstrong, consultant, department of dermatology, Ivan Stirling, consultant surgeon Craigavon Area Hospital, Craigavon BT63 5QQ

Minerva has noticed a growing enthusiasm for using infant bath seats in adult bathtubs. The devices are designed to help babies sit in bath tubs, but their slippery incline makes them dangerous. The compilers of a case series of drowning and near-drowning incidents warn that infant bath seats can offer a false sense of security to parents and carers, and that children should not under any circumstances be left unattended in them ( Journal of Paediatrics and Child Health ( 2004;40: 305-7[Medline]).

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