BMJ  2004;329:866 (9 October), doi:10.1136/bmj.329.7470.866

Minerva

What's been your biggest mistake? In this year's Christmas BMJ we want to include a collection of short articles about mistakes people have made. Your mistake might have been clinical, career, or otherwise—but if you refer to an identifiable person, before we can publish your story we will need written consent from that person or a relative. For advice, please go to http://bmj.com/advice/sections.shtml and look at "fillers." The deadline for receipt (which must be via our electronic submissions system) is 15 November.

Geriatricians deal with frailty. To intervene successfully, a variety of issues need to be addressed simultaneously, and such complexity consumes a great deal of health care. The trouble is that our healthcare systems have largely been designed to care for people who have only one thing wrong with them, and yet their chief users are those who have many things failing. Writing in Age and Ageing ( 2004;33: 429-30)[Free Full Text], two Canadian geriatricians argue that all of the wrong ways to address such complexity involve wanting old frail people to go away, to some more appropriate place, instead of trying to get to grips with how service is provided.

A clue about what triggers the destructive process involved in multiple sclerosis is reported in Nature Neuroscience ( 2004; doi:10.1038/nn1319). Scientists have found that in people with the disease, astrocytes (which are support cells) express abnormally high levels of a protein called syncytin. This is a remnant of a protein produced from a virus that invaded humans during primate evolution. Astrocytes expressing syncytin in culture produced compounds that were toxic to human oligodendrocytes, and mice infected with a virus that expressed syncytin showed multiple sclerosis-type motor impairment.

A GP complained about a drug advertisement that featured a couple walking, one behind the other, along a dry stone wall. It asked, "Have you ever heard someone's heart singing?" The complainant said that showing adults walking on top of the wall was inappropriate and might cause the wall to collapse, upsetting the farmer. The case was considered by a panel, which deemed that although the wall may have eventually been breached, there had been no such breach of the advertising standards code of practice ( Code of Practice Review 2004 August: 88).

The SMART (second manifestations of arterial disease) study, an ongoing prospective Dutch cohort study of patients with overt vascular disease or vascular risk factors, has found that the increased common carotid stiffness in patients with a carotid artery stenosis of 50% or more is associated with previous ischaemic stroke and transient ischaemic attack. The analysis suggests that measuring carotid stiffness may help in selecting high risk patients for procedures such as carotid endarterectomy ( Stroke 2004;35: 2258-62[Abstract/Free Full Text]).

More help for people with strokes has arrived in the form of new guidelines designed to help primary care teams deliver effective treatment and secondary prevention to stroke patients. The guidelines have been developed by the Action for Stroke Group and are based on the national clinical guidelines for stroke published in July. The information has been condensed on to an A4 sized card for easy access, and laminated copies can be requested from guidelines{at}avenuehkm.com or the guidelines may be downloaded direct from www.rcplondon.ac.uk

The Cochrane Collaboration, once referred to as the health services equivalent of the Human Genome Project, is 10 years old. Its core business is to produce systematic reviews that are regularly updated, the total so far produced standing at 2074. The collaboration has contributed to the development of research methodology, and the Cochrane Library is free to users in countries classified as low or middle income via HINARI, the Health InterNetwork Access to Research Initiative ( CMAJ 2004;171: 747-9[Free Full Text]).

We're in the middle of an era where wonder drugs are available to help us improve everything from our muscle mass and endurance levels, attention, memory, and ability to learn, to our emotional moods. The future is likely to see even safer drugs which will allow us to further manipulate all these aspects of life. At present, however, safe neurological enhancement remains a dream. When it does become a reality, will neurologists become "lifestyle consultants," asks an editorial in Neurology ( 2004;63: 951-2)[Free Full Text]. And will we have become a society in which neurological enhancements are routine?

Smoking remains the major risk factor for laryngeal cancer. This 48 year old man presented to the head and neck clinic for follow up after laryngectomy four years ago. An unusual distribution of nicotine staining was observed, affecting the skin of his left submandibular area and right hand first web space. Despite initial denial, this patient had continued to smoke, and devised an unexpected method of inhalation via his tracheal stoma. This case highlights the need to maintain smoking cessation advice and assistance to all patients who could benefit. Shailesh Agrawal (sagrawal{at}doctor.com), specialist registrar in otolaryngology North Manchester General Hospital, Manchester M8 5RB, Ajay Nigam, consultant otolaryngologist Blackpool Victoria Hospital, Blackpool FY33 8NR

Resources for health care in Afghanistan are tight, and that includes a distinct lack of human resources. Recruiting to rural areas is especially challenging; clinical officers currently have only three to six months of formal medical training, and laboratory support is very limited. A short report in the American Journal of Public Health ( 2004;94: 1686-8)[Abstract/Free Full Text] describes how women are under-represented both as patients and as health professionals.

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