BMJ 2003; 327 doi: https://doi.org/10.1136/bmj.327.7416.690 (Published 18 September 2003) Cite this as: BMJ 2003;327:690

Hospitals would be more efficient if they were run more like car factories, according to the latest report in Health Europe ( 2003,2; 56-67). The authors say that overburdened hospitals often have hidden reserves of operational capacity that can be unlocked by examining their process flow. Hospitals that borrow process-flow techniques from manufacturing could treat more patients at lower cost.

Anthrax may not kill by inducing endotoxic shock. A study of the effects of anthrax toxin in rats ( Journal of Clinical Investigation 2003;112: 656-8) found that toxin-induced death is mediated not by cytokine release, as previously thought, but by hypoxia-induced liver failure. These results suggest that the treatments developed for cytokine mediated septic shock will not be appropriate for treating anthrax.

A study of the effects of direct to consumer advertising of drugs in the United States (wheres it's legal) and Canada (where it's not; but it seeps across the border) in primary care revealed two separate effects. The primary effect is that patients are susceptible to advertiser's claims. The secondary effect is that doctors are susceptible to patients' requests for advertised drugs, even though they were ambivalent about drugs patients had requested ( CMAJ 2003;169: 405-12).

It's good news for shift workers and night workers. If overall energy balance is maintained, the human body can cope with small differences in meal sizes and meal times over 24 hours. The study ( Journal of Nutrition 2003;133: 2748-55) involved only seven healthy men, but the results suggest that it's no more favourable to eat a few large meals during the daytime than more frequent smaller meals around the clock.

Good nutrition crops up again in a randomised controlled trial of nutrition enhanced exercise for people with chronic obstructive pulmonary disease ( Thorax 2003;58: 745-51). Both groups performed better and their health status increased with exercise training. But in already well nourished participants, carbohydrate supplementation resulted in significantly better performance, which suggests a role for nutritional supplementation beyond simply treating weight loss.

In 1999 the Boston Medical Center became the 22nd US hospital in the Baby-Friendly Hospital Initiative. Earlier analyses showed that the rate of mothers starting breast-feeding had jumped from 58% in 1995 to 87% in 1999. The latest figures show that this success has been maintained: 87% of infants receive any amount of breast milk, and 67% of infants receive more breast than bottle ( Pediatrics 2003;112: e234-6).

Troubling foreskins no longer necessarily go under the knife; many are now being treated with topical steroids. An assessment of 100 consecutive referrals to paediatric surgeons in one centre found that by the time the children had reached the clinic about 30% were deemed normal for their age, and almost 40% were treated with steroids (81% of whom were treated successfully). Only 27% actually required surgery ( Journal of the Royal Society of Medicine 2003;96: 449-51).

Charlie Parker and Stan Getz both had major depressive episodes and were hospitalised at times. A study in the British Journal of Psychiatry ( 2003;183: 255-9) that targeted 40 eminent jazz players from the bebop era found that rates of mental illness were similar to those in other creative groups. Surprisingly the rate of bipolar affective disorder, which is conventionally linked with creativity, was not much higher than the lifetime incidence for the general population. Interpreting biography as fact may make people question these findings.

The sun and ultraviolet light are both good for people who have psoriasis, but there's a problem. A study that tested all three forms of ultraviolet light found it caused degradation of over 90% of calcitriol, the ointment used world wide to treat psoriasis. The ointment also reduced transmission of light-waves. The drug didn't break down in ambient or fluorescent light. The obvious conclusion is to advise patients to apply the ointment after phototherapy ( Journal of Investigative Dermatology 2003;121: 594-5).

A smoke-free café has proved financially successful in a city without smoking regulation policies. Two cafés in Switzerland that differed only in their smoking policies have proved equally popular and equally successful. Smoking status proved to be the key selection criterion among all the customers surveyed, of whom the vast majority said they preferred to have a choice of smoking and non-smoking areas ( Tobacco Control 2003;12: 282-8).

Norwalk virus infections are said to be the most important non-bacterial cause of gastroenteritis. The classic routes of infection are from food and by fecal-oral spread; less widely recognised is airborne infection. A report in Epidemiology and Infection ( 2003; 131: 727-36)of an outbreak in a school for children aged 4-11 found that pupils were more likely to become ill if another child had vomited in their classroom. The projectile vomiting common with Norwalk infections produces an aerosol which may be inhaled and which may contaminate the environment; the school needed intensive disinfection.


A 29 year old man with cystic fibrosis who had received a bilateral lung transplant three years earlier presented with sudden chest pain, dyspnoea, and tachycardia. In the previous 18 months his lung function had been progressively decreasing, and after infectious complications were excluded a bronchiolitis obliterans syndrome had been diagnosed. This remained uncontrolled despite immunosuppressive therapy. At admission, we observed jugular vein distension and subcutaneous emphysema that extended from the suprasternal notch and supraclavicular regions to the chest wall. High resolution computed tomography of the chest showed bilateral pneumothorax, pneumomediastinum, and subcutaneous emphysema that reached down to the abdominal wall. The patient underwent a second lung transplantation five days later.

Giovanni Taccetti, registrar, Filippo Festino, head nurse, Teresa Repetto, registrar, Silvia Campana, biologist, Maurizio de Martino, professor, Regional Cystic Fibrosis Center of Tuscany, Meyer Pediatric Hospital, University of Florence, Italy

Minerva likes reading long term studies, and one of the best and longest is Vaillant's follow up of the drinking habits of two groups of men who were recruited in Boston in 1940 (Addiction 2003;98: 1043-51). One group was made up of socially disadvantaged teenagers, and the other was drawn from people in their first year at Harvard. Observation showed that in both groups alcohol misuse could continue for decades without changing to remission, death, or progression to dependence. Vaillant concludes that we know far more about the clinical course of common cancers than we do of alcoholism.

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