BMJ 2004; 328 doi: https://doi.org/10.1136/bmj.328.7445.964 (Published 15 April 2004) Cite this as: BMJ 2004;328:964

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Gone are the days when cutting the chest wall open is always necessary for cardiac surgery. The rapid evolution of keyhole surgery has seen mitral valve procedures performed without sternotomy, using a left sided posterior mini-thoracotomy approach. A case series of 40 published in the Journal of Thoracic and Cardiovascular Surgery (2004;127: 1026-32) indicates that this type of approach not only offers a valuable option in more complex cases but also has acceptable levels of perioperative morbidity and mortality.

Waiting lists come with the territory of publicly funded health systems. As frustrating as waiting lists are for governments and patients alike, they serve a purpose when they're well managed. Maximised efficiency ensures a steady demand for precious resources such as staff, theatres, and beds, and some clinical problems spontaneously resolve during the waiting time. An editorial in the Journal of the Royal Society of Medicine(2004;97: 159-60) says we should focus more on the number of patients who have been treated, rather than the number still awaiting treatment.

Emergency departments are good places for drug companies to reach as many punters as possible. In the United States, drug companies' marketing expenditure rose by 70% between 1996 and 2000. An observational study conducted over 22 states found that an average of 42 items containing advertising could be seen in emergency departments. The most common items were pens, brochures, stethoscope labels, drug samples, mugs, and books (Academic Emergency Medicine 2004;11: 401-4).

One hypothesis about the cause of sudden infant death syndrome is upper airway obstruction during sleep. Is the syndrome more common in families with obstructive sleep apnoea? A case-control study in Thorax (2004;59: 337-41)found no difference in breathing during sleep between the parents of cases and control parents, and no major differences of control of breathing while they were awake, but the parents of cases did have slightly lower nocturnal oxygen saturation.

Paraffin oil often fuels the lamps used by orthodox Jews during the Sabbath and other religious holidays. Unintentional paediatric exposure to paraffin oil is usually by ingestion, with the risk of aspiration. A two year study in New York found that 71% of the 45 cases occurred in orthodox Jewish children, and just 9% in non-Jewish children. Demographic data weren't available for the remaining 20%. Over half the incidents occurred within 10 hours after a religious celebration (Pediatrics2004;113: e377-9).

Statisticians totting up the results of the 2001 UK census have a problem. They've identified one million fewer people than expected, and most of the missing are young men. For the first time there seem to be more women than men in this age group, which is a shame for the women. Emigration is one possible explanation, particularly considering that most of the missing are from places next to rivers that used to have great shipyards and coalfields (http://news.bbc.co.uk/ 6 April 2004).

Minerva isn't religious, but she was struck by a discussion about using the Bible to teach the essentials of quality improvement methods (Quality and Safety in Health Care 2004;13: 153-5). The book of Daniel is apparently a good place to start. Hypothesis definition, interventions, control and experimental groups, potential sources of bias, and a final policy change based on evidence can all be found in the first 21 chapters. The authors conclude that Daniel deserves to be known as a hero of quality improvement, not just as a near martyr.

When children eat their vegetables because of the promise of dessert to follow, it's not clear whether it's the promise of dessert or the motivation to earn a reward that makes them eat their spinach. Understanding this mechanism may help in understanding addiction. Monkey experiments show that neuronal activity in the orbitofrontal cortex increases in response to increasing reward, while that in the premotor cortex is related to the individual's motivational state (Science 2004;304: 307-10).

Given that use of benzodiazepines is generally frowned on, it's curious that in mental health units benzodiazepines seem to be flavour of the month for people with depression. An American survey found that over a third of inpatients with depression filled a prescription for a benzodiazepine, whereas 90% filled a prescription for an antidepressant. In contravention of most guidelines, inpatients received long term benzodiazepines; older patients tended to receive longer lasting supplies, but lower doses (American Journal of Psychiatry 2004;161: 654-61).

A cluster analysis of tools designed to gauge disease severity, quality of life, and psychological distress in 786 people who were admitted to hospital with psoriasis found that clinical assessments of severity differed greatly from patient centred measures (Journal of Investigative Dermatology 2004;122: 602-7). The authors say their findings emphasise the need for a reconceptualisation of the severity of psoriasis, and that both quality of life measures and body surface area measurements are both needed.

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An 80 year old woman underwent cataract surgery to her left eye as a day case procedure. On returning home she attempted to light a cigarette and her gamgee eye pad ignited. She sustained deep dermal and full thickness burns to her face and was admitted to the regional burns unit for several weeks of inpatient treatment. She had no serious eye injury but has considerable facial scarring as a result of the incident. Gamgee pads are made of cotton wool and gauze and are routinely used as dressings after eye surgery as they help keep the eyelids closed. They are highly flammable. Plastic eyeshields, used over a taped eyelid, are a less hazardous alternative for people who smoke. D W Lewis, senior house officer, L J Treharne,specialist registrar, P J Drew, consultant, department of burns and plastic surgery, Morriston Hospital, Swansea SA6 6PU

Substituting walnuts for monounsaturated fat in a Mediterranean diet succeeded in reducing concentrations of total cholesterol, including low density lipoprotein, and it also improved endothelium-dependent vasodilation in people with high cholesterol. The researchers think this finding might explain the cardioprotective effect of nut intake, beyond simply lowering cholesterol (Circulation2004;109;1609-14).

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