BMJ Articles - February 2010

BMJ Podcast - 01/02/10

Treatment of Clubfoot

· Many children suffer from clubfoot.

· Hippocrates wrote the first account of this in 400B.C.

· Most common historical technique for correction – extensive surgery or manipulative techniques. Often associated with stiffness and an associated limp in later life.

· Achilles Ternotomy – Ponsetti’s method is a new cheaply and easily carried out.

· Effective rehabilitation requires the parents to be motivated.

· 90% of children can expect a successful outcome – a pain free foot.

· Children essentially crippled for life can be ‘cured’.

Sharing health research data – research methods and reporting

· Why should researcher’s share their data? People should consider that if they have data they are not using, perhaps they could make it avalible to other people rather than having ‘lost’ data.

· Although studies are often very anonymised but if there is a large data set then it may be possible for patients to identify themselves.

· Come up with a list of 28 identifiers that researchers should take great caution about when releasing data set. These are ‘indirect identifiers’ which may lead the patient to identify their own data.

· Could data sets be shared after a period of ‘fair use’ is information is not published? Patients need to be told about this to give consent.

BMJ Podcast – 05/02/10

Urinary Tract Infections

· Managing these in primary care. This is a common disorder but new research has shed light on a well known condition.

· UTI is one of the commonest acute presentations in primary care.

· Majority are bacterial – usually treated by antibiotics.

· Commonest management is an immediate antibiotic prescription. Gold standard is mid-stream urine sample.

· Urinary dipsticks are also used to diagnose.

· Empirical delayed prescribing of antibiotics.

· Main outcome measure was severity of symptoms in a diary. There was no significance on severity of symptoms in all of the management approaches above. Demonstrated a 20% reduction in antibiotic prescribing.

· Triad of papers - trial / economic analysis / qualitative survey.

· Antibiotic resistance is relatively common in urinary tract infections.

BMJ Podcast – 12/02/10

Prescribing SSRIs with Tamoxifen

· New research shows that these drugs, prescribed together is not safe and leads to an increased risk of death.

· SSRIs interfere with the metabolism of Tamoxifen.

· This used to be a theoretical drug interaction but has now been quantified by a research institution in Toronto.

· Paroxetine was the SSRI involved in the trial and it is an irreversible selective serotonin re-uptake inhibitor.

· Patients should take care not to suddenly stop their Paroxetine.

· They should swap to another antidepressant.

Most medical school in the USA lack rules on ‘ghost writing’.

· Ghost writing is the practice of drug companies presenting a paper to academics and asking them to put their name to a paper they have not actually written.

· Reported authorship is essential for research integrity.

Why can't Scotland keep their discipline on the rugby pitch!?

It's quite difficult to find the words that can describe that rugby match. Final score Wales 31 - 24 Scotland after Shane Williams scored that last minute try in stoppage time to win the game. Scotland were 10 points up with 5 minutes to go. Unbelievable. Having played so well for 75 minutes it all fell apart when one moment of indiscipline led to a yellow card, Scotland a man down, Wales with all of the momentum, then it was all over. Scotland must do better. So well disciplined for the whole match and then one event to lose it all. Scotland won't have a better chance to beat Wales than that again for a long time. Ah well.

Down to some of the most interesting articles from the Student BMJ this month:

The cover article 'Health in the Homeless' was relevant to this week as one of the patients being seen by the community mental health team in Montrose who I'm spending time with this week are invoved in the care of a young woman who is homeless. As health professionals we are in a valuable position to help the homeless, since health services in the UK are still a relatively easy place for people to get access. It's also important that we engage with the homeless as often their ill health is one of the major barriers to getting them off the street, and also we have invaluable contacts with many other agencies who can help these people. Specifically to mental health, homeless people are 8 to 11 times more likely than the general population to be affected with many being admitted to a psychiatric hospital at some point in time. The incidence of suicide in the homeless is 35 times more than the general population. Alcohol dependence and substance misuse are other major co-morbidities in this demographic group. Unfortunately a lack of a permanent address, chaotic lifestyle and no access to public transport are barriers to health and a general mistrust of doctors can make people reluctant to seek help. An admission to hospital for these patients can be extremely beneficial if it leads to re-connecting them to help from social services and other sources of help.

Another interesting article:
Energy Drinks for Children - in the past 10 years there has been a massive increase in the number of 'caffeinated' drinks avaliable on the market, with sales marketing aiming at promoting their associations with power, youth and danger. Whilst caffeine is generally recognised as safe, it does stimulate the central and peripheral nervous system, improving concentration and performance in small amounts. Excess however can lead to GI upset, anxiety, agitation, sleeplessness and arrhythmias. In children these drinks should be avoided if possible and the long term effects of excessive consumption are unknown. Children and adolescents should be advised to stick to water if possible.

There was a section in the journal this month about notifiable diseases which I thought was useful for revision as one of the practice questions I came across this week was on this topic. A list of notifiable diseases can be found in the BNF. In the event that one of these notifiable conditions is identified, it would be one of the responsibilities of the junior doctor to notify a consultant in communicable disease. Further information is avaliable on the Health Protection Website: www.hpa.org.uk.

Finally, a report out this month shows evidence that antidepressants work only against severe depression and have little use in mild or moderate disease. (JAMA 2010;303:47-53). Drug treatment worked little better than placebo in a meta-analysis of patients with mild/moderate disease. All drugs investigated showed greatest benefits for only the most severely depressed.

Stem Cells, Sex Offenders & Synaesthesia

So many things I could write about this week, it's hard to know where to start really.

Stem Cell Spare Parts - following the story of the woman who had the first stem cell trachea transplant. What is the future of stem cell transplantation? Student BMJ.

In June 2008, a patient became the first recipient of a trachea grown from bone marrow stem cells and chondrocytes. There is still a great deal of ethical considerations and legislation surrounding stem cell transplantation but in this case the treatment was able to save the patient's life. Looking ahead to the future, the author stated that it was unlikely that it would be possible to grow full organs from stem cells because there are too many different cell types (13 in the kidney) whereas in the trachea there are only two. However it may be possible in the near future to develop parts of 'hollow' organs from stem cells, such as the colon, blood vessels and nerves.

Should sex offenders be castrated?

An article appeared in the BMJ this week on this highly controversial topic, written by a professor of criminal psychology and a professor in forensic psychiatry. In Poland in November 2009 following a series of sex offences , the Polish President signed a law allowing the chemical castration of some sex offenders using antiandrogenic drugs. The drugs reportedly offer a dramatic clinical effect with offenders reporting no longer being preoccupied by sexual thoughts and having a markedly decreased sexual drive. Overall I think the general message is that this could only be ethically applied if patients were to consent to having the treatment. Whether or not this has a role in 'forced' castration against the patient's will, I don't think so

Synaesthesia

This is a harmless neurological condition where senser are exaggerated and stimulation of one sense results in a number of abnormal perceptual experiences, such as Tuesdays are green and music is not only seen but tasted. There are a number of different types of synaesthesia described by different people eg spatial-sequence synaesthesia where a person experiences seqwuences of numbers in a 3D form eg Monday is infront of them to the right etc... Perceptions are usually besic eg a colour as opposed to "when I hear that music I see a flowery vase on the table". Synaesthesia was first described in Nature 126 years ago however it is only recently that a diagnostic test for the condition has been created. The abnormal perceptions are thought to originate from 'crosstalk' between areas of the brain which are not normally involved with one another. There is a high prevalence of synaesthesia in the general population although it's important that people with the condition are not labelled and stigmatised. It is apparently harmless but important to know about to save the patient being made concerned for no reason.

WHO Surgical Safety Checklist to be started as of 01/02/2010

In England and Wales as of this date, for every surgical procedure carried out, it will be mandatory to complete this surgical checklist. See the checklist here:

http://www.who.int/patientsafety/safesurgery/ss_checklist/en/index.html

Depression in Adults with a Chronic Health Problem

NICE have created a new set of guidelines in October 2009 on the management of these patients:

Depression is approximately 3 times more common in patients with long term chronic health conditions, with around 30% of patients affected. Severity of depression is determined by the number and severity of symptoms, and the degree of functional impairment. Presence of a physical illness can complicate the assessment of depression. The key goal of intervention in depression should be to achieve complete remission of symptoms.