BMJ 2004; 329 doi: https://doi.org/10.1136/bmj.329.7469.808 (Published 30 September 2004) Cite this as: BMJ 2004;329:808

A simple, low tech procedure seems to have resulted in 23% fewer deaths and 9% fewer readmissions to hospital for cardiovascular patients: the introduction of the patient care guidelines, including a discharge checklist for patients about the drugs they've been prescribed, reminder cards, follow up phone calls, and educational brochures. Researchers compared the records of 26 000 inpatients at a group of hospitals in the United States before the programme started and of more than 31 000 patients afterwards (Wall Street Journal 2004 Sep 21).

Wanted: enthusiastic members of the public interested in having their say about how the medical research agenda should be shaped in Britain. The Medical Research Council is inviting people to join two public involvement advisory groups that have been set up to expand the MRC's work on public health and research issues. Topics influenced to date include strategies for research into autism, Creutzfeldt-Jacob disease, and stem cell science. For more information email fatima.deabreu{at}headoffice.mrc.ac.uk by 8 October.

If you already have diabetes and have a heart attack, your chances are much worse than for your neighbour without diabetes. But what about people who have just developed diabetes? A study in Circulation (2004;110: 1572-8) compared people with previously known diabetes who had a myocardial infarction with people with a new diagnosis and those with no diabetes. It found that people with newly diagnosed diabetes had just as poor a prognosis as those with longstanding disease. The authors say that metabolic abnormalities must contribute to the adverse outcome after myocardial infarct.

Another, somewhat curious finding about diabetes is reported in Archives of Disease in Childhood (2004;89: 970-3). More than 4500 children up to the age of 14 diagnosed as having diabetes in Scotland presented initially in what seems to be a distinct seasonal pattern. Rates of presentation were significantly lower in holiday periods and at weekends in all but the youngest children (those under 4 years). Mondays and Fridays were the most common days. But is the pattern due to a lack of medical attention at those times, or due to a deferment by parents looking for help?

According to a review of general practice “items of service” (fee for service) payments in England and Wales, the number of claims for minor surgery rose by 11% from 1993 to 2000. Much of the rise was due to the use of cryotherapy to treat warts, which is apparently no better than using cheap products available over the counter. The new contract for GPs and the development of new special services should, say the authors, encourage the needs of the population to be better served (Journal of Public Health 2004;26: 264-7).

The Mercy Ship Anastasis (one of a fleet of floating hospitals that delivers medical aid to developing nations; http://www.mercyships.org) has just returned from Sierra Leone, which ranked last on the UN index of human development. Its crew, which included three dentists, three dental nurses, and one hygienist, spent seven months delivering free dental aid to more than 3000 people and performing about 8000 procedures. Sierra Leone currently has fewer than 10 dentists for a population of over five million (The Probe September 2004:4).

Human pancreatic and nerve cells have been shown to produce morphine and its precursors (more typically found in poppy plants). Culturing cells in the presence of labelled oxygen, scientists found evidence of the oxygen in all the morphine compounds. Although the function of mammalian produced morphine is still a mystery, the genes responsible for it may prove useful as a new pharmacological target for the treatment of pain (PNAS 2004;101: 14091-6).

Tea tree oil is another plant derived substance which has a multitude of medicinal uses. A study in the Journal of Investigative Dermatology (2004;123: 683-90) which investigates its anti-inflammatory properties reports that it reduces the developing cutaneous vascular response when applied to human skin 20 minutes after an injection of histamine. The exact component of tea tree oil that does this was identified as terpinen-4-ol, which seems to have a direct effect on the microvascular system, independent of the local sensory nerves.

The best way to insert a cannula into the internal jugular vein, avoiding the common carotid artery, is to use external landmarks. We're taught to rotate the patient's head, but how far? With the aid of an ultrasound probe, and trying a variety of head positions, anaesthetists discovered that rotating heads 45° or 60° left from the midline gave them a better chance of hitting the internal jugular vein while reducing the risk of getting into the common carotid artery. In fatter people, however, they suggest aiming for a rotation of no more than 30° (Anesth Anal 2004;99: 982-8).

Minerva has learnt somewhat late in life that although expressing anger feels good, it doesn't necessarily get her what she wants. A study of anger related personality traits in men with untreated high blood pressure has shown that having an “antagonistic disposition,” particularly a tendency to experience anger on the least provocation and a propensity to lash out, are linked to heightened carotid atherosclerosis. The authors can't comment on whether their findings apply to all cultures (Psychosomatic Medicine 2004;66: 633-9).

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A 34 year old woman involved in a road crash sustained a large forehead laceration and multiple pelvic fractures. She presented to the eye casualty one year later with mild blurring of vision in her left eye since the crash. Fundal examination showed a large choroidal rupture of the left macula. These injuries result from blunt trauma and generally have a good prognosis, but they may result in more serious complications, including retinal detachment. Ocular injuries should be considered in cases of multiple trauma, and dilated fundoscopy is advisable, especially if blunt trauma to the eye is suspected.

David Gilmour (dfgilmour{at}blueyonder.co.uk), registrar in ophthalmology, Peter Cackett, registrar in ophthalmology, Princess Alexandra Eye Pavillion, Edinburgh EH3 9HA

Long after parasitic infections have cleared, the human immune system remembers how to fight them off. Two different populations of T cells are needed: one to clear the parasite, which needs the parasite to be present, and a second group, known as “central memory” T cells, which stick around after the parasites have been eliminated. When scientists transferred central memory cells from mice infected with leishmaniasis into uninfected mice, the new mice were protected from subsequent leishmaniasis (Nature Medicine doi:10.1038/nm1108).


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