BMJ  2006;333:662 (23 September), doi:10.1136/bmj.333.7569.662

Minerva

Minerva

Minerva wonders if it's too early to start worrying about Christmas presents. One solution could be London Surprises, a delightful and informative paperback of nearly 100 anecdotes about people and places written and illustrated by two distinguished retired surgeons, Adrian Marston and John Blandy. You can get it from Begonia Press, 4 Hereford Square, London SW7 4TT.

A 24 year old Somalian woman was referred to the ear, nose, and throat department by an emergency nurse practitioner, who said that the patient's "uvula has fallen off and stuck onto the back of her tongue." The woman also had a three day history of worsening pain on swallowing with resulting anorexia. On examination, she had no uvula but a visible prominent oedematous epiglottis, and we diagnosed supraglottitis. This resolved within three days with intravenous antibiotics and steroids. It is common practice in Somalian communities to cut off the uvula within the first week of life in the belief that it promotes future good health and prevents weakness. Scott C Maskell (scottmaskell{at}hotmail.co.uk), senior house officer, Murali Sivanandan, senior house officer, Robert L Harris, specialist registrar, ear, nose, and throat department, St George's Hospital, London SW17 0QT

Coffee seems to have an interesting effect on patients with Parkinson's disease who take levodopa. A small double blind, randomised, crossover study found that caffeine shortened the duration of maximal plasma concentration of levodopa by hastening uptake of the drug. This resulted in the levodopa motor responses of walking and tapping taking effect more quickly and walking becoming stronger (Neurology 2006;67: 897-9[Abstract/Free Full Text]). The effect may be related to caffeine's inhibition of secretion of gastric acid, which in turn may enhance gastric emptying and absorption of levodopa.

Another food that may have a positive effect on functioning is tomato extract. A study in healthy humans found that tomato extract significantly reduced platelet aggregation, with no such effect observed with control supplements. Inhibition of platelet function was greatest in people with the highest plasma homocysteine and C reactive protein concentrations, suggesting that a dietary supplement of tomato extract may have a role in primary prevention of cardiovascular disease (American Journal of Clinical Nutrition 2006;84: 561-9[Abstract/Free Full Text]).

A patient had a near miss with death after a broken cerclage fixation wire that had been applied to his right patella migrated and found its way into his heart. The wire had been inserted 13 years earlier. Its presence in the right ventricle was discovered when he had a barium swallow to evaluate reflux symptoms, and he was referred immediately for open heart surgery to remove it. Surprisingly, the surgeons found no ventricular damage (Journal of Bone and Joint Surgery (Am) 2006;88: 2057-9).

A quarter of abortions in the United Kingdom are carried out in women who have had one before. A Scottish study of what happens when specialist contraceptive counselling is offered after termination of pregnancy found that women who had enhanced follow-up were more likely to opt for longer acting forms of contraception such as implants than women who received standard follow-up. But two years later, 14.6% of the intervention group had had another termination compared with 10% of the controls (Human Reproduction 2006;21: 2296-303[Abstract/Free Full Text]).

Sublingual immunotherapy with grass allergen tablets may be a viable and safe alternative to injections for patients who have seasonal allergic rhinoconjunctivitis. The primary efficacy analysis showed a reduction of 30% in symptom score and a 38% reduction in rhinoconjunctivitis medication scores compared with placebo. Some participants complained of mild itching and swelling in the mouth, but the tablets were generally well tolerated and fewer than 4% of the intervention group stopped taking the tablets as a result of side effects (Journal of Allergy and Clinical Immunology 2006;118: 434-40[CrossRef][ISI][Medline]).

Minerva has often thought about the bugs attached to her stethoscope, but what about public telephones? Bacteriological sampling of 50 public telephones in Turkey found 12 different types of bacteria, with the highest levels of contamination of mouthpieces occurring in October, and the lowest values in August. Streptococcus pneumoniae featured highly. The number of mouthpieces contaminated was about twice that of the earpieces (Journal of Infection 2006;53: 140-3[CrossRef][ISI][Medline]).

Exposing healthy volunteers to good (lemon) and bad (machine oil) smells while they experienced pain didn't produce the distraction or reduced perception of pain that researchers were expecting to find (Psychosomatic Medicine 2006;68: 613-6[Abstract/Free Full Text]). Instead, patients exposed to smells of either sort reported greater pain than those not exposed to any odour, which throws current ideas about pain and attention up in the air.

Phyllanthus niruri, a traditional plant treatment for renal stones, has been put to the test. The plant extract is used in Brazilian folk medicine and has no side effects. Italian researchers found that regular self administration of P niruri after extracorporeal shock wave lithotripsy increased the proportion of patients who were stone free after 180 days. The increase was significant for stones in the lower renal pole and tract (Journal of Urology 2006;176: 1020-2[CrossRef][ISI][Medline]).

If you have the misfortune to be severely injured, your best bet is to get taken to a centre that is staffed by full time trauma surgeons rather than one where the surgeons cover trauma part time. In a retrospective review of over 14 000 patients, multiple logistic regression showed a 50% increase in mortality for patients treated by part time trauma surgeons after adjustment had been made for age, sex, injury scores, hypotension, head injuries, day of the week, and night admission (Journal of Trauma, Infection, and Critical Care 2006;61: 272-9[CrossRef]).

Although general practitioners are encouraged to make generic referrals to secondary care specialists, a large proportion of them do not do this. A survey of 79 UK general practitioners found that the perceived clinical skills and competence of a named surgeon was the most important factor in choosing not to make generic referrals. Other factors that influenced their decisions were waiting times, personal rapport with the consultant, and feedback from other patients, in that order (Journal of Public Health 2006;28: 218-20).

The evidence suggests that intensive lifestyle interventions can achieve and maintain weight loss, but the evidence from primary care for the effectiveness of short interventions is "sadly scant." General practitioners are being asked to set up an "obesity register," but once these patients are identified there's no real commitment to tackling the problem. One GP says that if she's asked by a patient what can be done about obesity she's tempted to respond: "Ask me next year when I'm being paid to give you advice about it" (British Journal of General Practice 2006;56: 654-5[Medline]).

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