Minerva: March 2000

New objects tend to stand out in a familiar environment, and neurologists have now begun to understand why. Humans have frontal lobes that direct their attention to new visual stimuli (Journal of Neurology, Neurosurgery and Psychiatry 2000;68:18.24). In visual experiments, people with infarctions in the dorsolateral prefrontal cortex paid substantially less attention to new targets than did normal controls. This might explain the apathy characteristic of this kind of stroke, say the researchers.

Newborn babies love skin to skin contact. It's warm, comforting, even analgesic, according to a study in Pediatrics (www.pediatrics.org/cgi/content/full/105/1/14). Neonates laid naked but for a nappy on their mothers' chests during a heel prick cried 82% less than control infants laid in a cot. Other studies will have to examine whether skin to skin contact is any better than straightforward cuddling.

Patients often disagree with doctors over what is good for them, even when given the evidence from trials (Medical Journal of Australia 2000;171:9.12). Surveys of Australian patients show that they are much less likely to want treatment, even lifesaving treatment such as coronary artery bypass surgery, than their doctors think. This is unsurprising, says one commentator, and will continue until clinical trials examine the things patients really care about as well as morbidity and mortality.

A pilot study in 26 children suggests that ultrasound imaging is as good as traditional radiography for investigating isolated uncomplicated forearm fractures (Accident and Emergency Medicine 2000;17:22.4). If the finding is confirmed in larger studies, this is good news for parents who do not want to expose their children to ionising radiation, however small the dose.

Nurses can practise and prescribe independently of doctors in over half of American states, and there is growing evidence from primary care that they do the job just as well. Another study, this time a randomised trial (JAMA 2000;283:59.68), endorses this view, although the study period was short, the population highly selected (mainly Hispanic women in their mid.forties), and the design did not look directly at primary care skills such as making an accurate diagnosis and evaluating emergency patients for admission. A good start, concludes the accompanying leader.

Health professionals remain the gold standard, even for Californians seeking health advice. In one survey, 85% of Californians said doctors were their most trusted source of health information (Western Journal of Medicine 1999;171:302.5). The internet was ranked fifth, behind family and friends, the print media, and health information booklets.

Lovers of chocolate have kidded themselves for years that the saturated fat in chocolate, stearic acid, is less damaging than the saturated fat in a bacon sandwich. Data in last month's American Journal of Clinical Nutrition (1999;70:1001.8) finally lay the myth to rest. They show unequivocally that stearic acid is just as bad for coronary arteries as other saturated fats found typically in red meat and butter. Choose your poison.

Female genital mutilation is a continuing problem in Egypt despite a recent ban. Poverty and ignorance are often blamed for the practice, although a survey of students from Cairo, half of whom were female, shows that higher education for women is unlikely to eradicate it (New England Journal of Medicine 1999;341:1552.3). Over a quarter of 1020 respondents were against abolition of female circumcision. So were 24% of a subgroup of medical students.

High blood pressure is a well known risk factor for coronary heart disease, although at any given blood pressure some populations seem to be more at risk than others (New England Journal of Medicine 2000;342:1. 8). Japanese people and those from the Mediterranean countries of Europe can tolerate higher blood pressure than people living in northern Europe and America, according to the latest data from a 25 year old cohort study. Once again, a better diet is the most likely explanation.

Parents who search the internet for advice on how to treat their sick children may find accurate, useful information, but the chances are that they won't (www.pediatrics.org /cgi/content/full/105/1/1). Strategies for filtering out bad advice have been developed but all have serious limitations, not least because most internet users do not have access to the evidence they need to make an informed choice. Peer review of medical sites is one - costly - answer.

House staff in British hospitals can become attached to their tourniquets. So can large populations of micro.organisms (Lancet 2000;355:44). In one survey of 50 tourniquets from a selection of hospital departments, half were blood spattered and all grew a rich variety of skin flora. A quarter of the tourniquets grew Staphylococcus aureus and two were colonised by dangerous Gram negative bacilli. Infection control teams rarely take any notice of this humble tool; perhaps they should.

Bill Clinton's flexible personal ethics are once again under scrutiny following his decision to appoint a well known tobacco industry lobbyist to the powerful National Bioethics Advisory Commission. William Oldaker, whose own brand of bioethics presumably values free trade in addictive substances above an individual's right to health, may have persuaded Bill Clinton that he has the right credentials for the job, but others with less power and a better developed social conscience will be harder to convince.

This 69 year old woman was referred for excision of an infected sebaceous cyst on her neck. She had a large soft tissue mass in the midline on the posterior aspect of her neck which had been there since birth. A precautionary magnetic resonance scan showed a meningocele, Arnold.Chiari malformation, gross hydrocephalus, and a normal fourth ventricle. Congenital soft tissue masses close to the vertebral column should not be excised until imaging has excluded neurological malformation.

Elizabeth Bruce, house officer,
J J T Tate,consultant, department of surgery, Royal United Hospital, Bath BA1 3NG



studentBMJ 2000;08:45-88 March ISSN 0966-6494