BMJ 2002; 325 doi: http://dx.doi.org/10.1136/bmj.325.7374.1250 (Published 23 November 2002) Cite this as: BMJ 2002;325:1250

One of the essential ingredients of a high quality service is leadership. Another is that all work must be infused with compassion. Compassion is said to recognise the importance of every individual's action. Compassion does not forever forgive bad behaviour; it supports good effort while not tolerating destructive action (Academic Emergency Medicin e 2002;9:1067-9).

People with diabetes may need to watch not just what food they eat, but how they cook it (www.pnas.org/cgi/doi/10.1073/pnas.242407999). “Advanced glycation end products” are the toxic byproducts of spontaneous interactions between sugars, fats, and proteins, which trigger inflammation. They form quickly when food is cooked at high temperatures. With food cooked at lower temperatures, the low grade inflammatory state that leads to accelerated vascular disease in people with diabetes might be prevented—and indeed, eating food cooked at a reduced heat lowered concentrations of advanced glycation end products and of inflammatory markers.

Considerable controversy remains as to whether all the effort put into achieving a laparoscopic approach is worthwhile. A small controlled study comparing laparoscopic against abdominal hysterectomy for benign pathology found that laparoscopic surgery took 50% longer to complete—but these patients had significantly fewer complications, needed less pain relief, and were able to resume full domestic function and sexual activity earlier. Patients' satisfaction was also greater (Singapore Medical Journal 2002;43:403-7)

An opinion writer in Health Service Journal (2002 Nov 7:17) compares the escalating demands being made on the NHS with an “all you can eat” buffet. Not only do we eat far too much, he says, but we get upset if there is even a short wait between each groaning platter. This wouldn't happen at an expensive restaurant, where we'd realise that our meal was actually costing quite a lot.

Does encouraging people with high blood pressure to cut out salt, take exercise, and lose weight make any difference? A trial designed to assess the efficacy of simultaneously implementing all three took 44 overweight, hypertensive patients who were already taking one blood pressure drug and randomised them to a lifestyle or control group for nine weeks. The lifestyle group achieved significant reductions in total cholesterol, weight loss, and blood pressure (mean systolic reduction of 12.1 mm Hg and diastolic reduction of 6.6 mm Hg). The next step will be to see what happens in real life circumstances (Hypertension 2002;40:612-8)

Many people believe that psychological stress causes cancer, although the evidence for this is mixed. A Danish cohort study of parents whose child had died between 1980 and 1996 found that the death of a child is associated with a slightly increased overall cancer risk in mothers. The authors did not, however, observe an increased relative risk of breast cancer, alcohol related cancers, or hormone related malignancies, and fathers did not seem to be affected at all (Cancer 2002;95:2237-42). The relative youth of the parents enrolled may reduce the statistical power of the data.

Erythromelalgia is an aggravating disease characterised by redness, burning pain, and increased temperature of hands and feet. Non-steroidal inflammatory agents can relieve it, and standing on a cold floor may relieve symptoms in the feet. An investigation into its cause suggests that arteriovenous shunting, leading to decreased perfusion and tissue hypoxia, is the mechanism (Journal of Investigative Dermatology 2002;119:949-53)

Getting employees back to work after long term sick leave can be difficult. Sometimes it's a matter of poor motivation and personal problems, but with some conditions it seems that the employee's own doctor may contribute to the problem. The occupational physicians of 300 people off sick for three or four months with lower back pain say that physicians treating these patients should pay more attention to medical management, and seek advice from occupational physicians to reduce absenteeism (Occupational and Environmental Medicine 2002;59:729-33)

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An 81 year old woman who had had a total knee replacement 26 years ago noticed painless, knobbly swellings on either side of the knee. She was recently admitted to hospital with an acutely painful, swollen knee. Examination showed a pointing abscess on either side of the knee joint, and radiographs showed the dislocated prostheses. She underwent exploration, removal of the prostheses, and knee washout, with considerable relief of her symptoms.

The original arthroplasty was of the McIntosh type. In this patient, the prosthetic parts had been extruded from the knee, without causing symptoms. The knee eventually became painful when the overlying skin necrosed under pressure and then got infected.

K Srinivasan, senior registrar, A Nihal, consultant, M Lim, senior house officer, S T Kumar, senior house officer, department of orthopaedics, Hull Royal Infirmary, Hull HU3 2JZ

Extracorporeal shock wave therapy is not just for urologists—it's beginning to infiltrate into other bodily arenas. On the basis of a number of apparently positive observational studies of this treatment for chronic tennis elbow, a large randomised multicentre trial was set up to compare it with placebo. Sadly, in this trial its clinical success was no better than placebo (Journal of Bone and Joint Surgery2002;84A:1982-91)

They sell like hot cakes, but “ionised” wrist bracelets for musculoskeletal pain don't seem to confer any more benefit than placebo bracelets. A randomised double blind trial involving 305 participants found that both ionised and placebo bracelets produced a significant subjective improvement in pain, but the ionised ones were no better than the placebo version (Mayo Clinic Proceedings2002;77:1164-8)

A long time ago, people in Britain could obtain false teeth by mail order. Handcrafted false teeth are apparently still available in the United States, and visitors to one website will find detailed instructions about how to measure their dental arch, use a Bite-O-Meter, or fax their bite marks. Most styles of teeth available are “gorgeously grotesque” and will apparently help people who suffer from being too good looking (Dentist 2002;18(10):27).


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