BMJ  2003;327:E36 (4 October), doi:10.1136/bmjusa.01050006 (published 5 September 2002)

BMJ USA: Minerva

Minerva

This article originally appeared in BMJ USA

Colon cancers seem to be occurring further up the colon (from the left side to the right side), beyond the reach of a flexible sigmoidoscope ( Gut 2001;48:449-450[Free Full Text]. Studies from the United States, several European countries, and now Northern Ireland (pp 522-525) report a shift from left to right over the past decade or so. The findings may be the result of more sophisticated investigations picking up a greater proportion of proximal cancers, writes one commentator. Even so, the shift could spell the end for cheap and easy screening tools that fail to check the entire colon.

Minerva's long memory includes some of the many studies published during the past 40 years linking increased cardiovascular mortality and living in an environment with soft natural water supplies. This association has recently been identified in the Puy de Dome in France, where the water is very soft ( Environmental Research 2000;54:219-227[CrossRef]. Yet with all those years of research it remains unclear whether soft water is bad for us (perhaps because inorganic pollutants dissolve more easily) or hard water has some protective effect that is good for us.

US doctors who want a clear conscience and a truly independent practice can now pledge to be free of all drug company promotion by joining "no free lunch" (www.nofreelunch.org), a US campaign opposed to drug company inducements of all kinds. For $25, members receive a badge, a T shirt, and the resources to enlighten their colleagues and institutions about the malign influence of supposedly harmless gifts. One Canadian doctor writes that he was so wracked with guilt after a lavish night out that he took two years to get over it ( Canadian Medical Association Journal 2001;164:464[Free Full Text]).

It's hard to be warm, caring, and friendly all the time, but there's evidence that people respond well to a doctor with a good bedside manner, including a meta-analysis in ( Lancet 2001;357:757-762[CrossRef][ISI][Medline]). It concludes that outcomes in chronic diseases such as hypertension are generally better when the doctor is positive and reassuring, although the effects are small. These aspects of medicine are long overdue for some decent research: the emotional element of care has been ignored since Hippocrates first suggested it might be important, in 400 BC.

Most doctors believe that malignant disease and gallstones are the most common causes of jaundice, but a study on 121 patients in Wales ( Gut 2001;48:409-413[Abstract/Free Full Text]) found that although malignancy was the leading diagnosis, the next most frequent was septic shock, followed by cirrhosis. Doctors who were questioned put viral hep-atitis high among the common causes, but in this study it accounted for only two cases. Patients with jaundice are still most often referred to surgeons, though in practice few require surgery.

Samson may have been a biblical hero, but at least four doctors (presumed psychiatrists) from the University of California think he had antisocial personality disorder ( Archives of General Psychiatry 2001;58:202[Free Full Text]). They cite his fire setting, cruelty to small animals, bullying, fighting, and using a weapon—the jawbone of an ass—as evidence and say Samson meets six of the seven criteria defining antisocial personality disorder. While this kind of speculation about historical figures can be fun (or heresy depending on your point of view), it's usually fruitless. Proving the diagnosis is impossible.

Much of the increased mortality from heart disease in patients with diabetes seems to be due to a diabetic cardiomyopathy first described in 1972 but still unfamiliar to clinicians. A review in Heart 2001;85:247-248[Free Full Text]) says there are now "ample experimental, pathological, epidemiological and clinical data to support the existence of this cardiomyopathy." It goes on to recommend that all patients with diabetes (in addition to metabolic control) require aggressive lowering of the blood pressure and treatment with an angiotensin converting enzyme inhibitor drug.

When it comes to making decisions about life prolonging treatments, relatives and doctors are poor at guessing what incapacitated patients really want. But do advance directives help relatives make the right decision? Not according to a randomised trial in ( Archives of Internal Medicine 2001;161:421-430[Abstract/Free Full Text]). Various forms of advanced directive made no difference to an elected surrogate's accuracy, which remained around 70% for a range of conditions and outcomes. Hospital doctors were worse decision makers than relatives in a second randomised trial, but advance directives made them a little better.

Minerva's pitiful attempts at music making leave her envious of those with perfect pitch. She can blame her parents now that a twin study has shown that recognition of musical pitch is largely inherited ( Science 2001;291:1969-1972[Abstract/Free Full Text]. Researchers asked 136 monozygotic and 148 dizygotic twin pairs to listen to a variety of simple, well known tunes, some of which had wrong notes. They estimated that ability to recognise the wrong notes (pitch recognition) was between 71% and 80% inherited.

View larger version (113K): [in this window] [in a new window]   A 67 year old man presented to the accident and emergency department complaining of a "wobbly head." A radiograph of the cervical spine showed complete erosion of C2 and partial erosion of C3. We took biopsies of the affected bone and operated to fuse the first five cervical vertebrae. His osteomyelitis of the cervical spine was secondary to multiple dental abscesses, and resolved with antibiotic treatment. He made a full recovery from surgery. Amir M Khan, senior house officer, orthopaedics, King George Hospital, Goodmayes, Ilford IG3 8YB, UK

There have been many false dawns in the search for an effective treatment for severe sepsis, but the latest treatment, activated protein C, looks more hopeful than most ( New England Journal of Medicine 2001;344:759-762[Free Full Text]). It is antithrombotic, anti-inflammatory, and reduces mortality from sepsis by nearly a fifth, according to a large randomised trial. One expert commentator was so impressed, he says, that all patients with sepsis and end organ failure should be given the drug forthwith.

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