Drugs such as modafinil (an agent promoting wakefulness) are used to try to counteract the fatigue of multiple sclerosis (MS), but evidence for their efficacy is scant. A randomised, placebo controlled, double blind study of modafinil including 115 patients found no improvement after five weeks (Neurology 2005;64: 1139-43), although a randomised controlled crossover trial of aspirin in 30 patients with MS published in the same issue (1267-9) shows that the drug alleviated the problem. The authors propose that aspirin may work by blocking the output of the hypothalamus, which in turn affects the neuroendocrine and autonomic responses important in the perception of fatigue.

Patients with chronic breathing disorders tend to be quite anxious and are often depressed. In a cross sectional survey of over 1300 people 80% of them screened positive for depression, anxiety, or both (Chest 2005;127: 1205-11). The predictive value of a telephone screen test being positive was estimated to be 80%. What was more worrying in a population with such a high prevalence of anxiety and depression was the extent of untreated morbidity: just 31% were receiving help for their mental state.

Minerva wonders whether it's the technical challenge to surgeons or the advantage to …