BMJ  2004;329:1246 (20 November), doi:10.1136/bmj.329.7476.1246

Minerva

Is it really possible to give informed consent in the middle of having a heart attack? Most people with acute myocardial infarction are just too ill to give fully informed consent, but the author of an editorial in Heart ( 2004;90: 1237-8)[Free Full Text] argues that "consent is a state of mind, a decision by a patient." In these circumstances a patient may make a decision with very little knowledge, but with a lot of trust in the doctor. It's the dialogue between doctor and patient that is critical, and it must be pitched at a suitable level for the patient.

The number of medical conferences held worldwide each business day has jumped by a whopping 50% in just 12 months. A press release for the medical industry conference Calendar Newsletter reports this as the conference business returning with a vengeance—but many budgets for travel and meetings have been frozen or reduced, making it likely that attendance figures at each meeting will drop by about half. Minerva wonders if anyone can prove a 50% increase in the "proven benefit to health" and suspects that the equivalent expenditure could be better spent.

Mild anaemia in older people is relatively common and most of it can't be easily explained, but it shouldn't just be put down to normal ageing. Even mild levels of anaemia have an impact on morbidity and mortality, and the causes most frequently identified are iron deficiency, renal failure, and chronic inflammation. The large number of cases of unexplained anaemia has led to the idea of a new entity, "anaemia in the aged," which might relate to defective hypoxia sensing ( Blood 2004;104: 2263-8[Abstract/Free Full Text]).

Minerva recently heard of a service designed to help smokers quit. "textmeareminder" will send regular text messages to mobile phones or phone messages to landlines to remind people not to light up. They can be set to arrive at your most vulnerable time of day, when temptation's high. The cost of each message works out less than a single cigarette (£1.50 for seven messages) (ncannings{at}textmeareminder.com).

Most studies of the effects of blood pressure on cognitive functioning have focused on elderly people. A study in Hypertension ( 2004;44: 631-6)[Abstract/Free Full Text] shows that younger people are just as much at risk. Cognitive performance was followed up for 20 years in 529 people who fell into either of two age ranges: 18-46 years and 47-83 years. Higher blood pressures were significantly associated with cognitive decline in both groups.

Minerva remembers how tedious she found processing patients through preadmission clinics for simple surgical procedures. An audit of what actually happens within one preadmission clinic for adults in an ENT department reports that most of the changes made by the doctors after the clerking performed by nurses (ordering more blood tests, chest radiographs, and electrocardiograms, as well as cancelling procedures due to hypertension) could have been eliminated, thus freeing up the doctors, had the nurses simply worked to a better designed protocol ( Journal of Laryngology and Otology 2004;118: 796-8).

Adopting personal best peak flow readings into asthma action plans produces better health outcomes than using predicted peak flow targets. But how long after a change of treatment should peak flow readings be assessed? Analysis of data from a trial involving 61 people with poorly controlled asthma at the start found that the most useful way of defining the personal best peak flow is the highest peak flow reading over the previous two weeks. With twice daily monitoring, the peak flow reaches a plateau after just a few weeks ( Thorax 2004;59: 922-4[Abstract/Free Full Text]).

Europe has seen its fair share of the making and breaking of nation states, usually in the name of social modernisation. According to a writer in the American Journal of Public Health ( 2004;94: 1894-904)[Abstract/Free Full Text] the impact that such change brings to the health of the people living in these areas is not necessarily positive or easily reversible. He illustrates his point with the disintegration of Yugoslavia. The impact on health is that many of the improving measures of mortality that were seen before the collapse have been replaced by increasing disparities afterwards.

The Atkins diet seems to produce mixed responses among those who try it. In contrast to the positive experience of Daniel Wheeler (p 1245), a GP says, "The constant drip of protein did banish hunger pangs, but my initial joy at being allowed cheese—a no-no on previous low fat diets—fry-up bacon and eggs breakfasts, and massive steaks soon faded." By the end of week one she was "Atkins-bored," her bowels ground to a halt, and she was soon chewing sugar-free gum endlessly to disguise bad breath ( Health and Ageing 2004 November: 11-2).

Despite a host of possible confounding factors, a large cohort study in the British Journal of Psychiatry ( 2004;185: 366-71)[Abstract/Free Full Text] reports a significant association between exposure to painkillers in the second trimester of pregnancy and a risk of more than fourfold of schizophrenia in the offspring. The categories of analgesia included both prescription and over the counter preparations, although the authors say they couldn't separate out preparations used to reduce fever from those taken for pain.

A 50 year old man used clobetasol propionate (a highly potent steroid cream) for a facial rash that he described as "redness of both cheeks." Four months later, he was referred urgently with a florid rash typical of severe rosacea. Rosacea is a chronic inflammatory facial dermatosis of unknown aetiology characterised by erythema and pustules. Treatment is with topical metronidazole or, in severe cases, systemic tetracycline. In the short term topical steroids can improve the appearance in rosacea, but long term usage may worsen or even induce the condition. Annette Loffeld (Annette.loffeld{at}blueyonder.co.uk), specialist registrar, Chin Y Tan, consultant, Skin Centre, City Hospital, Birmingham B18 7QH

 

A young woman who underwent conventional appendicectomy without burying of the appendix stump presented again just two months later with a recurrence of right iliac fossa pain. Computed tomography showed a healthy stump and an inflamed fluid-filled cavity below the wound, which at laparoscopy proved to be a 3 cm distal remnant of the appendix. Its histological appearance was consistent with persistent appendicitis. Post-appendicectomy appendicitis is rare but does happen, and its cause is incomplete removal ( Journal of the Royal Society of Medicine 2004;97: 543-4[Free Full Text]).

In a continued effort to improve door to needle time for patients with ST elevation acute myocardial infarction, one hospital moved the place where thrombolysis was given from the coronary care unit to the emergency department. Before the change, the median door to needle time was 64 minutes; it went down to 35 minutes after the change ( Emergency Medicine Journal 2004;21: 676-80[Abstract/Free Full Text]).

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