In 1984 a Department of Health working party decided to cut drastically the number of medical students entering British universities because the spectre of medical unemployment appeared on the horizon. A personnel officer at Cambridge University was quick to point out the shortsightedness of the arithmetic (The Times 11February 1984). Rather than closing medical schools, he suggested recruiting more mature students in order to reduce the homogeneity of the medical profession. History's hard to swallow in light of the staffing crisis now hitting the NHS.

It has been said that a good physician appreciates the difference between postponing death and prolonging the act of dying. An American study that questioned whether specialists differ on do not resuscitate decisions found that specialists in chest and critical care medicine recommended do not resuscitate orders more strongly than cardiologists, general physicians, and junior doctors. Among the juniors, the strength of the order increased with clinical experience (Chest 2002;121:957-63).

After directing his energies for seven years to preventing direct to consumer advertising, David Kessler, former commissioner of the US Food and Drug Administration, has now recanted. Addressing drug and advertising executives in Boston last week, he admitted that his fears about misinformation and confusion had not materialised. He warned, however, that advertising would probably get caught up in future debates over rising drug costs (page A2, Boston Globe 17 April 2002).

Diltiazem hydrochloride (DTZ) 2% ointment performs as well as glyceryl trinitrate 0.2% ointment for treating chronic anal fissures—and causes far fewer headaches (British Journal of Surgery 2002 89:413-7). But there's a downside to using drugs rather than surgery. As resting anal pressures are likely to revert to pretreatment levels when treatment is stopped, early recurrences of fissures can be expected.

Dispensing doctors seem to prescribe more drugs than prescribing doctors. This may be explained by a shorter repeat prescribing interval: for dispensers it's usually 28 days, whereas for prescribers it's upwards of two months. Or this difference might be due to the non-cashing of prescriptions, which is more likely to happen in prescribing practices (Dispensing Doctor 2002;18:14-5). But Minerva is amused by the third explanation offered: that patients in dispensing practices prefer to be given prescriptions for drugs that can be bought more cheaply elsewhere.

A novel treatment for acromegaly has recently arrived. It's a growth hormone receptor blocker called pegvisomant. This compound makes no attempt to control pituitary tumour growth or reduce secretion of growth hormone, and its efficacy doesn't depend on the characteristics of the tumour. It simply acts on all tissues targeted by growth hormone. The next challenge, says a writer in Clinical Endocrinology (2002;56:423-5), is to achieve biochemical control while still containing tumour growth, preserving pituitary function, and optimising quality of life.

Injuring one ear is unfortunate, but a simultaneous injury to both ears is downright careless. A prospective survey of 111 patients with presumed accidental ear injuries presenting to one English children's casualty department found that 56% of the injuries were lacerations of the pinna and 7% were caused by cotton buds (Emergency Medicine Journal 2002;19:226-8). Bilateral ear injury, especially in very young children, is extremely rare and may raise suspicions, say the authors.

Should the new UK primary care trusts be worried? According to the World of Work (2002;42:11-3), some central and eastern European countries are unable to deliver even the most basic affordable health care, and health staff are paying the price for this failure. The reasons for such decline include a shift from state provided health care to insurance based financing, decentralisation, and a greater emphasis on general practitioners.

“Smart sutures” could be created from the threads of a new, degradable material that tightens up once sewn into the body. Scientists have designed a shape memory thermoplastic polymer that resumes a previously held shape after a temperature increase of several degrees. If it catches on, the polymer should make it easier to tie sutures in confined spaces (Science Express Reports www.sciencemag.org/sciencexpress/recent.shtml; published online 25 April 2002; 10.1126/science. 1066102).

Six obese patients with type 2 diabetes were put on a very low calorie diet and taken off their hypoglycaemic agents. After just two days, those whose fasting blood glucose concentrations barely went up after an intravenous glucose challenge could be distinguished from those whose levels deteriorated. The responders continued to do well at 10 and 30 days, and both groups lost weight (abstracts of the 14th “Internistendagen” in Netherlands Journal of Medicine 2002;60:50-1).

The old Edinburgh Royal Infirmary's replacement is due to open next spring and is a modern (some might say characterless) affair. The one remaining part of the new hospital yet to be designed is the sanctuary (formerly known as the chapel). Members of the old school hope that some of those who have passed through its portals during their career might wish to contribute to the sanctuary in the new Royal Infirmary. Please contact Dr A D Toft on 0131 536 2092.

Figure.

A 46 year old man was Scottish country dancing. After a skip to the left he felt a sharp pain in his left groin and found he was unable to bear weight. He gave no history of injury or surgery to either hips or pelvis. Clinically he had a shortened, flexed, adducted, and internally rotated left leg. Radiographs confirmed a posterior dislocation of an otherwise normal left hip. The hip was reduced under general anaesthetic. Subsequent plain films and computed tomography confirmed satisfactory reduction with no acetabular fracture. He was mobilised, allowed to bear weight after four weeks, and returned to full daily activities without symptoms by two months.

Dislocation of the hip from a simple twist is extremely rare. In a normal hip it is almost always associated with a high energy injury such as in a road crash.

Angus Maclean, specialist registrar in orthopaedic and trauma surgery, Glasgow Royal Infirmary, Glasgow G4 0SF