BMJ  2006;332:1042 (29 April), doi:10.1136/bmj.332.7548.1042

Minerva

Minerva

Many hospital patients are confused about whether to call their doctor "Doctor" or "Mister" (or "Miss"). Just when they start to get the hang of it, they're caught out again. Now they have physicians, dressed like surgeons, sticking a cardiac stent in them—and wanting to be called doctor. And the stent insertion is an intervention, rather than an operation, because it's not carried out by a card-carrying surgeon. In the US, of course, "Doctor" will do for every vet, dentist, osteopath, and podiatrist (Journal of the Royal Society of Medicine 2006;99: 164-5[Free Full Text]).

View larger version (75K): [in this window] [in a new window]   A 69 year old woman was referred by her general practitioner to the general ophthalmology outpatient clinic with bilateral eyelid irritation and loss of eyelashes on her left lower lid. A biopsy of the lower lid confirmed the presence of a basal cell carcinoma. She was referred to the oculoplastic service for surgical excision, after which tumour-free margins were confirmed. Infiltrating basal cell carcinomas may present in this seemingly trivial way, without evidence of a mass lesion. Clinical suspicion should be high if there is localised loss of eyelashes, and such cases should be referred for assessment and biopsy. Oliver Baylis, senior house officer (Oliver.baylis{at}chs.northy.nhs.uk), Stephen Morgan, consultant, department of ophthalmology, Sunderland Eye Infirmary, Sunderland SR2 9HP

Endotracheal intubation should be done as quickly and as smoothly as possible. Repeated attempts to intubate can harm and kill, so knowing when to stop is important. Out of hospital rescuers often need several attempts to intubate successfully, and prospective data from 42 emergency services suggest that three attempts offer reasonable opportunity for intubation outside of the hospital environment (Academic Emergency Medicine 2006;13: 372-7[CrossRef][ISI][Medline]).

Automated external defibrillators should also be handled with care outside hospital. They depend on a critical rhythm analysis algorithm that interprets the electrocardiogram. A case report in Circulation (2006;113: e672[Free Full Text]) describes how, when a 75 year old man collapsed outside, ventricular fibrillation was correctly identified and a shock successfully delivered. P waves reappeared, but the algorithm persisted in identifying ventricular fibrillation, resulting in a second, inappropriate, shock.

Defects in knee cartilage are commonly treated by filling them with fresh osteochondral allografts that have been kept at low temperatures. A study in the Journal of Bone and Joint Surgery (2006;88A; 762-70) reports that articular cartilage from six cadavers stored at 4-6°C showed time-dependent loss of chondrocytes in tissue stored for more than 15-20 days. Allografts transplanted into non-human primates after 21 days of storage degenerated more severely than those that had been stored for less than 21 days.

In light of serious adverse effects in a recent UK drug trial, a study of why people volunteer for early phase gene transfer research in Parkinson's disease makes interesting reading (Neurology 2006;66: 1010-5[Abstract/Free Full Text]). A major concern was that the participants may have unrealistic expectations—but the decision to take part in such trials depended mostly on patients' attitudes to risk, their optimism about science, and being oriented towards action, rather than on their clinical, functional, or demographic characteristics.

The nature versus nurture debate has caught Minerva's attention again. A large study recently found that common genetic polymorphisms are important determinants of obesity, which—apart from being a risk factor for cardiovascular diseases—is a heritable trait. DNA samples obtained from participants in the well known Framingham heart study show that up to 10% of individuals may have the genotype predisposing to obesity (Science Express 2006;doi: 10.1126/science.1124779[Abstract/Free Full Text]).

Studying medicine in physically dangerous environments can be more stressful for students from outside this background than for students who are accustomed to living under such conditions, say researchers. A study comparing Israeli and American medical students studying in Israel found that American students reported higher levels of anxiety, which had a significant impact on their daily lives (Medical Education 2006;40: 389-93[CrossRef][ISI][Medline]).

Teachers' estimates of problem behaviour detects boys who could be susceptible to frequent drunkenness in later life, according to a Finnish study. The 10 year, population based follow-up study found that problems related to hyperactivity in childhood was correlated with both occasional and frequent drunkenness at age 18. Conduct problems at age 8 predicted frequent drunkenness (Addiction 2006;101: 512-21[CrossRef][ISI][Medline]).

Minerva was happy to learn that there may not be any meaningful relation between watching television and symptoms of attention-deficit/hyperactivity disorder (ADHD). In contrast to recent studies, which had postulated a link between the disorder and television viewing, researchers conclude that watching television is a weak predictor of developing ADHD symptoms (Pediatrics 2006;117: 665-72[Abstract/Free Full Text]).

You may feel healthy, but if you are hypertensive and smoke you could have a weak heart. A multi-ethnic study of atherosclerosis has found that higher diastolic blood pressure and smoking are associated with a decrease in regional left ventricular function in asymptomatic people. The study indicates that these two independent variables had an additive effect on ventricular function (Journal of the American College of Cardiology 2006;47: 1150-8[Abstract/Free Full Text]).

An editorial in Pain Medicine (2006;7: 57-9[CrossRef][ISI][Medline]) calls out "to those with the power of inquiry, the skills to teach, and the desire to heal." More than 4000 studies related to pain are published each year, and just 1% of these address the topic of pain and ageing, says the author. Chronic pain in old age has become the normal expectation of healthcare workers and patients alike, and it often goes untreated. It's time to put this right.

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