BMJ 2003; 327 doi: https://doi.org/10.1136/bmj.327.7412.458 (Published 21 August 2003) Cite this as: BMJ 2003;327:458

Clever mathematics has shown that despite the general poor outcome of cardiac arrest in the community, rapid defibrillation by targeted but non-traditional responders is probably good value for money compared with standard emergency medical services. The data came from US casinos, which were encouraged to place sufficient defibrillators on the scene to ensure that no more than three minutes elapsed from the time of collapse. The authors say that the incidence of arrest should be considered when choosing locations for public access defibrillators (Circulation 2003;108: 697-703).

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A healthy 22 month old white boy presented with a four day history of progressive wheeze and non-productive cough. On examination he had evidence of respiratory compromise, and a chest radiograph showed air trapping on the right,suggestive of an aspirated foreign body. Bronchoscopy showed a sizeable mass of granulation tissue completely obstructing the right main bronchus and compromising the left one, and biopsies showed acid fast bacilli. He responded to debulking of the right main bronchus mass, antituberculosis therapy, and corticosteroids.Mycobacterium tuberculosis is well known for mimicking more common conditions and must be considered even in patients considered to be at low risk.

Russell A Cathcart, senior house officer, Andrew Clement,specialist registrar, Neil Geddes, consultant, ear, nose, and throat department, Royal Hospital for Sick Children, Glasgow G3 8SJ

Nerve conduction tests are conventionally used to confirm a diagnosis of carpal tunnel syndrome, but ultrasonography may prove a feasible alternative. German doctors found that a cross sectional area of more than 0.11 cm2 in the proximal carpal tunnel, combined with compression signs on longitudinal scans, proved highly predictive for the syndrome. Ultrasonography gave a sensitivity of 89% and a specificity of 98% for the diagnosis (Neurology2003;61: 389-91).

Can risk be modified for breast cancer? A plethora of epidemiological studies show that women who engage in vigorous exercise for 3-4 hours each week have a 30-40% lower risk for breast cancer than sedentary women, and overweight women have a 50-250% greater risk for post-menopausal breast cancer. The data is observational, but a writer in Oncologist (2003;8: 326-34) says that, given the international trends for obesity and decreasing physical activity, the impact of a population-wide adoption of greater physical activity and less energy imbalance could be large.

Although treatment guidelines say we should be using selective serotonin reuptake inhibitors for panic disorder, a 10 year study inAmerican Journal of Psychiatry (2003;160: 1432-38) found only a modest rise in their use. The overall pattern of psychotropic drug use remained stable, with benzodiazepines still being most commonly used for panic disorder. Interestingly, patients taking selective serotonin reuptake inhibitors did no better than those taking benzodiazepines, and they didn't have better remission rates.

Do teaching hospitals offer an increased intensity of services, or are they less efficient than non-teaching hospitals? A US study found that when children with common conditions were admitted to teaching hospitals, they stayed in more than half a day longer than similar admissions to non-teaching hospitals. A similar pattern was identified for children with underlying chronic conditions, who would usually be admitted preferentially to teaching hospitals (Pediatrics 2003;112: 278-81).

Rabbits fed diets rich in cholesterol develop many of the features of Alzheimer's disease, so they are used to model the disease. When scientists added copper supplements to the diets of these rabbits, they developed significantly more Alzheimer-type plaques and plaque precursors than rabbits that just ate cholesterol rich food. They also performed less well when learning a difficult conditioning task. The combination of copper and cholesterol may prevent the brain from removing β-amyloid, the protein that induces plaque formation (Proceedings of the National Academy of Sciences www.pnas.org/cgi/doi/10.1073/pnas.1832769100>).

Responding to an article in Psychologist (2003;16: 401), a reader says it is inappropriate to set oneself up as a psychotherapist and invite clients to sit in a room and engage in client centred therapy, and at the same time claim to offer no “interventive strategy.” Just sitting in the room with someone who regards you as their therapist constitutes an intervention.

Minerva smiles when people wince at the price of nicotine replacement therapy but still find the money to buy cigarettes. In Australia, the impact of tobacco tax reforms on tobacco use was closely observed. During the first two phases, the impact of the tax rise was offset by greater retail discounting, and the fall in smoking consumption was less than expected. In the third phase, smokers were unable to cushion themselves from the sharp price increases that occurred (smokers paid 25% more) and the fall in consumption was considerably higher than expected (Tobacco Control 2003;12(suppl II): ii59-66

As with old dogs, the nervous system seems limited in its capacity to learn with increasing age. Neuroscientists reporting in Nature Neuroscience (2003;advance online publication http://dx.doi.org/10.1038/nn1115>) watched naturally occurring rearrangements of axon terminals in mice. The neurons had been engineered to express a fluorescent protein, allowing the scientists to image individual nerve terminals over time. Growth and retraction took place rapidly in young mice, and remodelling decreased significantly by middle age.

Survivors of childhood cancer often need help from fertility services later in life. A strategy for fertility services (Human Fertility 2003;6: A1-40) says that oncology units should ensure that all competent females have the opportunity of discussing the preservation of their fertility by conservation of a sample of gonadal tissue or oocytes before toxic treatment or removal of ovarian tissue. Although cryopreservation is an experimental technique, preservation is intended to create future opportunities as techniques develop.

Loosening your tie helps in hot weather, and it may also reduce your intraocular pressure. Twenty people with normal eyes and 20 patients with open angle glaucoma had their intraocular pressure checked with their shirt collar open and when wearing a tight tie. In both groups, intraocular pressure increased when the tie was worn; in some cases it went into the range where diagnosis and management could be affected ( British Journal of Ophthalmology 2003;87: 946-8).

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