BMJ 2008; 336 doi: https://doi.org/10.1136/bmj.39576.648472.47 (Published 15 May 2008) Cite this as: BMJ 2008;336:1138

A retrospective review of 100 confirmed cases of malignant melanoma shows that biopsies were inappropriate in a significant proportion. It also found that national guidelines for suspected melanoma—which recommend a prompt, full thickness excision biopsy allowing both a diagnosis and an assessment of the Breslow thickness of the lesion—are not being followed. Not only were punch biopsies being performed even when excision biopsy is feasible, but only a small proportion of patients were seen within 14 days of referral (Annals of the Royal College of Surgeons of England 2008;90:322-5; doi: 10.1308/003588408x285856).

Persistent enhanced attention and spatial memory in young animals have been linked to supplementation with choline during fetal development, and deficits show up when choline is restricted. But in human children aged 5 years, IQ and visuospatial processing were not related to maternal and cord blood choline concentrations (American Journal of Clinical Nutrition 2008;87:896-902; www.ajcn.org).

Acute respiratory distress syndrome (ARDS) can complicate mechanical ventilation but may be preventable in some cases. A retrospective analysis of more than 2500 patients who had received more than 48 hours of ventilation, and in particular of the 19% of the 789 who developed ARDS in hospital, found that high peak inspiratory pressures and increasing positive end-expiratory pressure are important risk factors. Non-ventilator risk factors for ARDS include sepsis, low pH, raised lactate, low albumin, and transfusions of packed red blood cells and plasma (Chest 2008;133:853-61; doi: 10.1378/chest.07-1121).

How do psychiatrists deal with issues of faith, culture, and dietary requirements when they prescribe for their patients? A small survey with a 40% response rate indicates that most psychiatrists are aware of the presence of potentially forbidden ingredients derived from animals in drugs, but only half of the respondents said they thought they should have a discussion with patients before prescribing such drugs (Psychiatric Bulletin 2008;32:179-82; doi: 10.1192/pb.bp.107.018051). Showing awareness may help reduce non-compliance and improve the trust between patient and doctor.

When the anterior collateral ligament ruptures, bone bruises that show up on magnetic resonance images are created. The patterns of bruises may relate to the mechanism of injury: contact or non-contact. Among 256 patients undergoing ligament reconstruction surgery, 86 were included in the non-contact mechanism group, and 14 in the contact mechanism group. In the non-contact group, bone bruising was more frequent, deeper, and more intense in both medial and lateral compartments of the knee (American Journal of Sports Medicine 2008;36:927-33; doi: 10.1177/0363546508314791).

The BMJ was recently taken to task for carrying out of date information. The Disabled Drivers’ Association and the Disabled Drivers’ Motor Club are referred to as separate organisations, but in fact they merged in 2005 to create Mobilise, a campaigning charity promoting mobility for all disabled people. For information on all aspects of driving, vehicle adaptations, wheelchair and scooter users, parking badges, etc go to www.mobilise.info (or telephone 0150 848 9449).

Osteopoietic stem cells are transplantable and have been shown to engraft successfully within the bone marrow of recipients, and therefore have potential to treat some bone disorders such as severe osteogenesis imperfecta. A study in mice exploring why the accelerated growth of cells diminishes over time (Blood 2008;111:4386-91; doi: 10.1182/blood-2007-10-115725) found that normal bone marrow donor stem cells with osteopoietic potential engraft after transplantation, but these cells offer only limited regenerative contribution to osteopoiesis in the host. The cause of the decline seems likely to be in the microenvironment.

Testing the hypothesis that recovery is quicker after the two incision total hip arthroplasty technique than the mini posterior incision technique, surgeons in the US have discovered in a randomised controlled trial that the opposite is true. Patients who had just one incision recovered more quickly (Journal of Bone and Joint Surgery 2008;90A:1000-6; doi: 10.2106/JBJS.G.00804).

A new ultrasound technique to transiently expand perflutren-lipid microspheres, which in turn transmit energy momentum to surrounding fluids, has been put to the test with systemic tissue plasminogen activator. Stroke patients treated within three hours had abnormal residual flow, measured with transcranial Doppler, before receiving the treatment. Perflutren microspheres reached and permeated beyond intracranial occlusions, with no increase in bleeding, after systemic thrombolysis (Stroke 2008;39:1464-9; doi: 10.1161/STROKEAHA.107.505727).

What are “neurohospitalists” and what do they do? According to Neurology they are neurologists who devote at least a quarter of their time to managing inpatients with neurological disease (2008;70:1282-8; doi: 10.1212/01.wnl.0000308949.45423.13). Their aim is to provide efficient, cost effective care by reducing the length of hospital stay. Advertisements for these specialists have increased over the past few years, but little is yet know about their true value. What is clear is that they are likely to be most useful in hospitals with high patient volume and many resources.

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