BMJ  2004;329:1296 (27 November), doi:10.1136/bmj.329.7477.1296

Minerva

It's not just aberrant sexual encounters between doctors and their patients that are frowned upon. The UK High Court recently heard the case of a senior, well respected general practitioner who had had an illicit affair with a patient. Despite the consensual nature of the affair, he was accused of and pleaded guilty to the charge of serious professional misconduct. The view was taken that sex between doctors and their patients can never be considered truly mutual, or based on an equal footing ( UK Casebook 2004;12: 4).

We're entering the merry months of seasonal affective disorder, which is commonly followed by mild hypomania in the spring and summer. One hypothesis is that this pattern of hibernation is an adaptive evolutionary mechanism, which enhanced the likelihood of reproductive success for females living at temperate latitudes. Hypomania increases the likelihood of procreation, and becoming pregnant in the summer means giving birth in the spring, when babies would have a higher chance of survival ( Medical Hypotheses 2004;63: 767-72[Medline]).

Observations of what happens during another seasonal adjustment is found in Occupational and Environmental Medicine ( 2004;61: 893-8)[Abstract/Free Full Text]. In this case it's the effects on mortality and emergency hospital admissions during hot weather and heatwaves in London. The researchers found no overall relation between high temperatures and admissions, but they do report evidence for heat related increases in respiratory and renal disease and admissions in very young children and people over 75. The increase in daily mortality rate during heatwaves suggests that many deaths occur because people do not come to medical attention.

The cost of a total hip replacement in US hospitals is greater than in Canadian centres, despite significantly shorter in-patient stays in the United States. Some of the biggest differences in cost were for the prosthetic elements used. The countries could learn something from each other: the Canadians could adopt strategies to shorten the length of admissions, and the Americans could seek to control their unit costs ( Journal of Bone and Joint Surgery 2004;86-A: 2435-9).

Extracorporeal shock wave therapy (ESWT) is trying to find other niches than lithotripsy, particularly as a treatment for tendon related pain. But a randomised controlled trial comparing ESWT and physiotherapy versus sham ESWT and physiotherapy as a first line treatment for tennis elbow found no significant difference between the groups within eight weeks of starting treatment ( American Journal of Sports Medicine 2004;32: 1660-7[Abstract/Free Full Text]). Perhaps ESWT should remain in the domain of the urologists.

Another study with negative results is reported in the Archives of Disease in Childhood ( 2004;89: 1037-8)[Abstract/Free Full Text]. It's been proposed that houseflies are a reservoir and vector for Helicobacter pylori, so researchers devised a trial of insecticide spraying in villages in the Gambia to judge its effect on H pylori infection in young children. The intervention proved effective at controlling flies, but not at preventing H pylori infection.

Some people say that a bowl of porridge oats for breakfast helps to reduce cholesterol levels. A study in the American Journal of Clinical Nutrition ( 2004;80: 1185-93)[Abstract/Free Full Text] now reports that consuming barley as part of a healthy diet may be effective at reducing total cholesterol and low density lipoprotein in men and women with mildly raised lipid levels. Barley proved more effective than other sources of soluble fibre.

It's easy to dismiss transient ischaemic attacks (TIAs), but mini-strokes are not just a warning of strokes; they should, it's argued, be investigated in the same way as full blown strokes. A large observational multicentre study reports that TIAs are not as benign as we think, and that there is a relevant individual risk of early stroke, death, or disability from TIAs. It suggests that the management and treatment strategies for TIA and acute stroke should be similar ( Stroke 2004;35: 2453-8[Abstract/Free Full Text]).

Doing the rounds: an NHS rowing team raced against a Japanese team. There were eight men in each, of similar fitness, but the Japanese team won by a mile. Top NHS management established a committee of analysts, which reported that the Japanese had seven rowers and one captain, whereas the NHS has seven captains and one rower. They called for restructuring. The new team comprised four captains, two service managers, and a director. After a second lost race, the single rower was dismissed on the grounds of incompetence, and the management team received a bonus for strong leadership. A new boat is currently being designed.

"Learning by doing" is losing favour in the medical community, particularly for invasive procedures, and web based teaching is becoming the order of the day. Consensus statements from a conference for informatics and technology in emergency department health care conclude that the web will soon enable medical students and junior doctors to see one, simulate many, do one competently, and teach everyone ( Academic Emergency Medicine 2004;11: 1149-54[CrossRef][ISI][Medline]).

A 78 year old woman presented with a complete left anterior chamber hyphaema and loss of vision, having tripped on the pavement and knocked her head. She had had phacoemulsification cataract surgery 12 months before, without complications. As the hyphaema resolved, loss of the iris (through the iatrogenic corneal wound) became apparent, but the capsular bag and lens implant were intact. Although such cases are rare, as cataract extraction and falls are endemic in the elderly population we believe this presentation will become increasingly common. Hiten G Sheth (drhitensheth{at}yahoo.co.uk), senior house officer, Edward Herbert, fellow, Alistair H Laidlaw, consultant, department of ophthalmology, St Thomas' Hospital, London SE1 7EH

The youngest chairman of the Royal College of General Practitioners has an admission to make. He recently queued for more than an hour to meet... Pamela Anderson. He thought the queue was for a Bill Clinton book signing, but when Mayur Lakhani discovered his mistake he nevertheless felt obliged to pick up a copy of the model's salacious semi-autobiographical novel Star. He says he has yet to read it ( Times 26 November 2004: 5).

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Rapid Responses:

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Discrepancy in the photos

Mandagere R Vishwanath
bmj.com, 7 Dec 2004 [Full text]

minerva to dismissive of extracorporeal shock wave therapy for tendon pain

alan f. rosenfelder
bmj.com, 9 Dec 2004 [Full text]