BMJ 2004; 328 doi: https://doi.org/10.1136/bmj.328.7444.904 (Published 08 April 2004) Cite this as: BMJ 2004;328:904

Caffeine consumption can put your blood pressure up acutely, but if you're drinking coffee on a daily basis, is this likely to be clinically significant? Individual differences in tolerance were investigated in a randomised controlled trial conducted over four weeks. Although raised systolic and diastolic response to the final caffeine challenge was completely lost in half the participants, the other half showed no loss of response, despite moderately high levels of daily intake beforehand (Hypertension 2004; 43: 760-5).

Minerva, in common with most doctors, has at times tried to convince patients to make lifestyle changes. But how many of us are actually taught how to do it properly? A study in the Mayo Clinic Proceedings (2004; 79: 327-31) shows that teaching specific skills, such as patient centred motivational interviewing, to medical students enhances both knowledge and confidence about counselling patients, which could stand the students in good stead whatever career path they eventually take.

Between 1% and 4% of the populations of developed nations are diagnosed as having a learning disability. With the whole population enjoying an increased life expectancy, it's time to recognise a greater capacity of people with learning disabilities to enjoy a longer and more fulfilled life. A writer in Developmental Medicine and Child Neurology (2004;46: 219) says it's encouraging to note that improved life expectancy reflects not only positive changes in healthcare delivery but, in some countries, society's growing capacity to accommodate an enriching group of young people.

Pulsatile tinnitus is quite rare, but it should be swiftly investigated because in some people it may indicate the presence of a treatable condition. A series of 136 consecutive patients with confirmed cervicocephalic arterial dissection found that 16 (12%) presented with pulsatile tinnitus (Journal of Laryngology and Otology 2004;118: 193-8). The most common finding at angiography was irregular stenosis, most of which normalised during follow up. The authors say that a high index of suspicion and early angiography will avoid a delay in diagnosis.

When communities decide to build bicycle and pedestrian trails, the financial planning needs to include what type of surface is planned, the length of the trails, and whether bridges are involved, as well as anticipated maintenance costs. A cost analysis of the built environment in Nebraska concludes that improved cost effectiveness will come from encouraging more people to use trails, and from researching ways to reduce the cost of creating them (American Journal of Public Health 2004;94: 549-53).

As many people present atypically with coeliac disease as present with the more classical triad of steatorrhoea, diarrhoea, and weight loss. A long follow up of a cohort of patients already diagnosed as having coeliac disease and put on a gluten-free diet shows that the diet substantially and rapidly improved all the gastrointestinal symptoms previously reported, not just the typical ones. The authors point out, however, that their cohort was a highly motivated group, which included few teenagers (American Journal of Clinical Nutrition 2004;79: 669-73).

More sneaky manoeuvrings by the tobacco industry have been unearthed. An analysis of one airline's in-flight air quality study, conducted and sponsored by several tobacco industry companies in 1988, found that unfavourable findings were apparently deleted by industry scientists and lawyers before delivery to the airline. The study ignored the health implications of respirable suspended particles, promoting instead the industry's position that better ventilation could solve any problems posed by secondhand smoke (Tobacco Control 2004;13(suppl 1): 20-9).

A common problem for pathologists examining hysterectomy specimens is finding pronounced tissue autolysis. But it seems to be easy to prevent. An injection of formalin into the endometrial cavity through a needle passed alongside a probe through the external cervical os, on the same day as removal, significantly reduces the degree of autolysis and greatly reduces the risk of histological interpretation becoming impossible. In this study, the risk of stripping the surface cervical glandular epithelium off with the probe proved to be theoretical rather than actual (Journal of Clinical Pathology 2004;57: 332-3).

According to research carried out in Manchester, the disparity in funding for medical research in England is linked to health inequalities across the country and also to regional economic disparities. The “golden triangle” of London, Oxford, and Cambridge receives over two thirds of the national £1.5bn pot of charity and public money made available each year for medical research. Ideally, the golden triangle will become a larger golden polygon, across the whole country, with each region having its own centre of excellence in medical research (Health Service Journal 2004 April 1: 32-3).

Immunotherapeutic strategies for metastatic malignant melanoma are showing promise, as is the idea of combining a modified autologous melanoma cell vaccine with interleukin-2, a biological immunomodifier. Researchers analysed the response and survival rate of 34 patients with metastatic melanoma who received a vaccine. Interleukin-2 was given to 24 of the 34. Twelve patients overall had an objective tumour response; two who had received the vaccine alone, while the other 10 had received the combination of vaccine and interleukin-2. Skin reactivity to the vaccine seems to predict tumour response (British Journal of Cancer 2004;90: 773-80

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The bent thumbs of this 3 year old girl were diagnosed by her general practitioner as thumb contractures after a fall. Her thumbs were not painful. These are trigger thumbs, a developmental deformity of early childhood. Often they no longer trigger, and are fixed at presentation. The condition may be unilateral or bilateral. A nodule, known as Notta's node, is commonly palpable at the base of the thumb. We reviewed all referrals from general practitioners from 1994 to 2002 (37 children); as it is an uncommon condition, they had some difficulty making the diagnosis. Surgical release gives excellent results.

Sarah Irby, specialist registrar, James Murray, specialist registrar, David Williamson, consultant, orthopaedic department, Great Western Hospital, Swindon SN3 6BB

Dishing out needles and syringes to injecting drug users to prevent HIV infection is big business in New York City. But a year after a programme designed to increase access to the equipment started, only 17% of those practitioners who responded to a postal survey knew about the programme, and only 2% thought they were registered with it. Over half said they would be willing to take part, but more people said they'd be happy to prescribe syringes, rather than distribute them directly (Clinical Infectious Diseases 2004;38: 438-41).

Guidance at bmj.com/advice

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