BMJ 2005; 331 doi: https://doi.org/10.1136/bmj.331.7510.244 (Published 21 July 2005) Cite this as: BMJ 2005;331:244

Community based mental health services are commonplace in the United Kingdom but rare in Eastern Europe. The report of an attempt to map out what happened to 50 new patients seeking care for mental health issues in countries such as Albania, Croatia, Macedonia, and Romania says that most sought help from general practitioners, directly from psychiatrists, or hospital doctors, but that GPs rarely played a “gatekeeper” role, and they usually prescribed only sedatives for these patients. The police, priests, and healers could also be involved. Patients took an average of three weeks from first seeking help to arriving at psychiatric services (British Journal of Psychiatry 2005;186: 529-35).

More babies than ever are being diagnosed with allergy to cows' milk and are being fed with soy formulas or extensively hydrolysed whey formulas from a young age. A cohort of 168 such babies followed up to age 2 years found that the nutritional status and growth of babies using both types of formula were well within the reference ranges, suggesting that the choice of formula for babies with allergies can be made largely on the basis of what the infant tolerates (American Journal of Clinical Nutrition 2005;82: 140-5).

As the Vikings invaded northern Europe from Scandinavia they left a strong genetic legacy. Genetic surveys, using forms of DNA passed down through either the mother or the father, on the isles of Orkney and of Shetland, north of mainland Scotland, find Scandinavian ancestry in about 44% of people on Shetland and 30% of those on Orkney. Equal contributions from both sexes suggests these islands were settled by Viking families. In the Western Isles and Skye, however, the overall Scandinavian ancestry is much lower, and the DNA is mostly found in the men, suggesting that lone males travelled further west and settled with women from the British Isles (Heredity 5 April 2005; doi 10.1038/sj.hdy.6800661).

According to analysis of a large set of data from general practice, patients with asthma are at a significantly increased risk of developing gastro-oesophageal reflux disease, mainly during the year after diagnosis. The authors also report a non-significant trend for people with gastro-oesophageal reflux disease to develop asthma. One hypothesis is that altered respiratory physiology may predispose to acid reflux, perhaps by respiratory obstruction resulting in negative pleural pressures, which in turn increases the pressure gradient between the thorax and abdominal cavity (Chest 2005;128: 85-93).

Nasal surgery may help severe migraine: a report of 21 people who had surgery to stop the opposite surfaces of their nasal cavities or sinuses pressing against each other suggests this endoscopic procedure may be an option in those patients whose migraine fails to respond to drug treatment. The procedure more than halved the number of days with migraine and reduced severity of symptoms (Cephalalgia 2005;6: 439-43).

One guideline marker of the quality of the emergency services is that they meet an eight minute response time. But a retrospective cohort study of emergency ambulance calls in one year in a US city reports that after several factors—including the severity of the illness—were controlled for, a paramedic response within eight minutes was not associated with improved survival to discharge. The study identified a survival benefit with response times within four minutes in cases where patients were at medium or high risk of death (Academic Emergency Medicine 2005;15: 594-600).

While we're out enjoying the warm summer weather, spare a thought for children who are left in unattended vehicles. A study that recorded temperature in a car over the course of an hour on 16 sunny days found that, regardless of the outside temperature, the rate of temperature rise inside the car didn't change. The average rise was 3.2°F (1.7°C) per five minute interval, with 80% of the rise happening during the first 30 minutes. The average total rise was 40°F (22.2°C). Leaving the window open slightly didn't slow the rise in temperature (Pediatrics 2005;116: 109-12).

The size of a region in the brain may determine why some people cope with trauma better than others. Scientists explain in PNAS (www.pnas.org/cgi/doi/10.1073/pnas.0502441102) that certain traumatic memories can be linked with specific cues, resulting in long term conditioned fear. If people are exposed to the cues in the absence of new trauma, a “safety” memory is created which quells the fear. Researchers using visual stimuli and electric shocks observed that those volunteers with a thicker ventromedial prefrontal cortex had smaller electrical skin responses, indicating better retention of safety memory, and thus less fear.

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A 35 year old woman presented to the emergency department with sudden dysphagia to solids and liquids after a mild upper respiratory tract infection that had been treated with augmentin. A history of trauma was excluded. Ecchymoses of the anterior neck had spread to the chest. Flexible nasendoscopy showed a retropharyngeal haematoma extending to the supra glottis, confirmed by computed tomography. There was no clinical evidence of infection, inflammatory markers were not raised, and the clotting profile was normal. A differential diagnosis of a blood reaction secondary to penicillin allergy was proposed. The patient made an excellent recovery within 48 hours after penicillin was stopped.

R J D Hewitt (rjhewitt{at}hotmail.com), senior house officer, R Kuchai, specialist registrar, N Eynon-Lewis, consultant otolaryngologist ear, nose, and throat department, St Bartholomew's Hospital, London

If performances are to succeed, be they from actors or doctors, they must appear truthful. The skill of a good performer blinds the audience to the artifice that is employed. Bedside manner, for example, is often switched on with a show of interest that lives only in the lips and cheeks while the eyes remain dead. These sorts of antics rarely fool patients. Writing in the Journal of the Royal Society of Medicine (2005;98: 323-4) a doctor who has long worked with non-medical performers says that the more a medical performance is based on understanding, the more likely it is to be therapeutic.

A non-invasive device that measures central aortic pressure changes could help prevent unnecessary hospital admissions for people with chest pain. The device consists of three components—a sphygmomanometric arm cuff attached to an air pressure unit, an array of sensors attached to the arm over the brachial artery, and a computerised monitoring system. Preliminary findings suggest that with a threshold value for pressure change that indicates acceptable cardiac performance to rule out heart attack, 40% of patients presenting with acute chest pain could be spared an admission and more invasive cardiac testing (Emergency Medical Journal 2005;22: 486-9).

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