Minerva

Minerva has had her knuckles gently rapped, once again. Commenting on her recent reporting of a study that found that the inexperience of junior doctors had little impact on patients' outcomes in intensive care, a reader says, “Surely she is aware that junior staff have minimal or non-existent influence in intensive care, at least in the UK. One could assume that over the pond, the US would also rely on more senior staff in ITU to make decisions, and hence be little influenced by changes in junior staff.” He says that the authors were probably looking in the wrong place.

Anal sphincter damage after childbirth is much more common than we think. A meta-analysis of 717 vaginal deliveries showed that 26.9% of primiparous women had anal sphincter defects and 8.5% of multiparous women had new sphincter defects. Fortunately, at least two thirds of defects caused no symptoms, although it's been calculated that the probability of faecal incontinence associated with an anal sphincter defect is about 80% (British Journal of Surgery 2003;90: 1333-7).

A longitudinal study comparing on-road driving performance in healthy older adults with that of people with very mild or mild early stage Alzheimer-type dementia provides good evidence that driving ability becomes poorer over time. The group with mild dementia received a rating of “not safe” sooner, and complex regression analysis indicates that baseline age is an important risk factor for a rating of “not safe.” The study not only supports the view that driving assessments are necessary, but also that they should be repeated over time (Journal of the American Geriatrics Society 2003;51: 1342-7).

Another thing that may affect driving ability is pupil dilation. A study of 16 young adults who were licensed drivers reports that when their pupils were dilated their ability to recognise low contrast hazards—and to avoid them—was significantly reduced (British Journal of Ophthalmology 2003;87: 1387-90). Their visual acuity also reduced, and sensitivity to glare increased. The drop in visual performance, however, was not significantly related to reduction in driving performance.

Two independent groups of researchers have shown that transplanting a single haematopoietic stem cell produces inflammatory cells that travel to sites of muscle damage and fuse with muscle cells, leading to muscle regeneration in mice (Nature Medicine 2003; advance online publication, doi:10.1038/nm959 and 10.1038/nm963). The work is promising for possible treatments of diseases such as Duchenne muscular dystrophy, but the authors say a lot of work is needed to improve the efficiency of the muscle generating process.

Minerva's mind sometimes wanders from the job in hand. That said, she would have been keen to participate in a study that used functional magnetic resonance imaging to examine what happens in the brain when people try to suppress a particular thought, or all thoughts, or allow themselves to think freely about anything. The researchers found that the anterior cingulate was greatly activated when a particular thought was suppressed, but a more widespread network of neural activity occurred when subjects suppressed all conscious thoughts (Neuropsychologia 2003;41; 1863-7).

A survey mentioned in the November 2003 supplement of the Emergency Medicine Journal says that at any one time in the United Kingdom, a fifth of emergency medicine consultants are moving jobs. Such a high figure may reflect that it's more of a sellers' market at the moment, or the greater variety of job plans on offer. But it's like the upsurge in the housing market (which won't last either); the advice given to those with itchy feet is to move now.

A physician urges us to recognise suffering. It is more individualised and elusive than pain, he says, and may go unrecognised and undertreated even among very compassionate caregivers (Annals of Internal Medicine 2003;163: 2429-32). He writes, “While we may not be able to alleviate suffering in the same manner or to the same degree as we can physical pain, the simple recognition of suffering in the patient is the first step in a truly holistic approach, allowing the patient to feel the therapeutic power of compassion and begin healing.”

Abdominal adipose tissue has a direct influence on health, and visceral fat correlates with health risks more than fat elsewhere. It's also been shown that increased visceral fat (as measured by magnetic resonance imaging) has a stronger correlation with waist circumference than with the body mass index. Better, then, to monitor waist circumference with a tape measure, if the aim is to influence health (American Journal of Clinical Nutrition 2003;78: 902-3).

Compared with more sedentary people, athletes display greater skin perfusion for the same increase in core temperature. One explanation for this might be that athletes develop cutaneous blood vessels that respond more to vasodilatory stimuli. When this was put to the test in a series of complex experiments, it seems that the increase in nitric oxide bioactivity in the dermal micro-circulation in athletes might be one of the adaptations brought on by endurance training (Journal of Investigative Dermatology 2003;121: 1197-204).

A 5 year old boy presented with a history of intermittent tachypnoea noted by the community midwife. His antenatal history had been unremarkable, with normal antenatal scans. He had been born by spontaneous vaginal delivery, had not required resuscitation, and had been discharged home at 6 hours of age after an unremarkable examination. He had been breast feeding well. A chest x ray showed a left sided congenital diaphragmatic hernia, which was successfully repaired surgically. The practice of early discharge means that this diagnosis is no longer made only on neonatal units. Community staff need to be aware of this rare potential diagnosis. Anu Morjaria, specialist registrar, David Brookfield, consultant, department of paediatrics, North Staffordshire University Hospital, Stoke on Trent ST4 6QG

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An increasing volume of evidence suggests that even minor psychological symptoms are linked with an increased risk of death. Almost 10 000 male students at Glasgow University were interviewed between 1948 and 1968. Their temperament was assessed, and 9.7% of the total were recorded as having one or more temperament types other than “stable.” Students with more than one temperament type had a higher risk of death from stroke and cancer. A label of “anxiety” was positively associated with cancer deaths and “hypomania” with an increased risk of a cardiovascular death (Journal of Epidemiology and Community Health 2003;57: 888-92).

Guidance at bmj.com/advice