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.

Fighting Cervical Cancer and Management of Women who Decline Blood products in Pregnancy

A couple of articles drew my attention this week as sent out in an email, released by the medical school.

Fighting Cervical Cancer in Under-Resourced Countries
David McGregor and Adeola Olaitan. the Obstetrician and Gynaecologist. Jan 2010.

Cervical cancer is not merely a condition prevalent in more economically developed countries. It is a condition which is preventable and in the UK a vaccine has now been produced which targets the human papilloma virus. However this may not be avaliable in many poorer countries. It is tragic that this preventable form of cancer still claims the lives of hundreds of thousands of women every year. 80% of cervical cancer deaths occur in under-resourced countries. In high resource countries such as the UK the number of deaths have been reduced now by 90% with the vaccine and cervical screening programmes in place. Low awareness of the condition is a major barrier in poorer countries. New methods of prevention are now emerging, such as the prospect of human papilloma virus DNA testing and visual inspection with acetic acid. Sreening and immunisation processes are only likely to succeed with sufficient patient education to go along side it.

The second article regards a review on how to manage women who decline blood products during pregnancy for religious reasons of for concerns regarding their safety.

Review: Management of women who decline blood and blood products in pregnancy.
Jane Currie, Matthew Hogg et al. The Obstetrician and Gynaecologist. Jan 2010.

Mortality rates are significantly increased amongst these women and antenatal councelling must involve a senior management team. Considerable efforts are required to optimise pre-delivery haemoglobin and identify risk factors for haemorrhage. Intra-partum techniques to avoid blood transfusion include cell salvage and early recourse to definitive surgical management in the event of a massive obstetric haemorrhage. Women's autonomy can be respected with accurate information and empathic councelling.

The Wii Knee

The first entry today is a BMJ Case Report released in June 2009 regarding medial meniscal tear injury whilst playing on the Nintendo Wii.

Almedghiol SM, Shablahidis O, Rennie W, Ashford R. Wii knee revisited: meniscal injury from 10-pin bowling. BMJ Case Reports 2009; doi:10.1136/bcr.11.2008.1189

A 23 year old woman presented to the orthopaedic clinic with right knee pain, sustained whilst playing bowling on the Wii. Meniscus tear is one of the most common injuries of the knee, cuased by axial loading and rotational force. The knee became swollen immediately after the incident although the patient was able to go about her normal business in the aftermath. She presented three months later with pain and tenderness over the medial aspect of her knee. On examination there was a mild effusion of the right knee with tenderness along the joint line and a full range of motion maintained. What made this case un-usual was that usually meniscal tears are caused by contact sports injuries whislt this was an example of a 'non-contact' event. Investigation is MRI scan and treatment can be either medical, surgical or conservative. This case provides a worthy reminder that serious injuries can be caused by these games and people should take care!

Examination of the Knee: Revision
Inspect for muscle wasting, swelling, deformity, loss of full extension.
Feel for any effusion, patella and joint line.
Move to flexion and extension.
Function test collateral ligaments, and cruciate ligaments (anterior and posterior Drawer tes.
Further details on examination of the knee is in the ARC Musculoskeletal Assessment for Medical Students DVD.

The medical news making the headlines this week was regarding the postcode lottery for patients being given weight loss surgery.

Kmietowicz Z. Postcode lottery persists over weight loss surgery despite NICE guidance
22 January 2010, BMJ 2010;340:c427

Reports said that sometimes in the same hospitals patients with BMIs of greater than 60 were not being offered surgery whilst patients with a BMI of less than 40 from a different postcode were receiving bariatric surgery. The issue here does represent a somewhat ethical dilemma as to delivering equality of healthcare. Surgeons have reportedly said that there is no evidence to support the use of surgery in treating the most seriously ill, but it is cost-effective providing surgery, as consts of the operation will be re-couped within 3 years of the operation from money saved by obesity management. A quote: "In the UK an estimated 1 million people meet the NICE critria for obesity surgery and of this number around 240,000 have expressed interest in the surgery, yet only 4300 weight loss operations were carried out in 2009". The surgeons are calling for a long-term strategy that ensures all patients have equal access to equal access to treatment from appropriately equipped centres.

Haiti, Anthrax poisoning, Neurophobia and Racism

In the news this week was the devastating earthquake which hit Haiti, the poorest country in the Western Hemisphere. It seems now that between 50 and 100 thousand people have lost their lives and the photos show near 'apocalyptic' scenes. This made me think about the challenges to doctors and healthcare for people there. This week I've been in the A&E department or Ninewells. The centre is fully equipped to cope with all ranges of injury and the doctors have all of the resources they require at their disopsal. I think the biggest tragedy about Haiti is that a vast number of lives could probably have been saved with limited interventions eg. IV infusions, oxygen etc. There must be extremely limited resources and I wonder how the doctor's and aid workers in Haiti are coping at present. The loss of life in the whole incident is awful and the whole thing has been playing on my mind alot this week, thinking about the broader access to healthcare around the world. It just seems so unfair at times.

A few other things which took my attention this week from the BMJ.
Multiculturalism in the NHS - the experience of a not so foreign "foreign doctor". A Low.
A reminder by a doctor born in the UK but of Chinese origins that racism in the workplace is still common and that racial stereotyping does occur in clinical practice. He says that although he has lived in UK all his life, he frequently is asked questions such as 'How are you finding the climate over here then?'. It just reminded me about the multi-cultural nature of the UK at present and the benefits of having such an environment to live in.

Surgeons swear when operating: fact or myth? F Fausto Palazzo, Orlando J Warner
These guys did a study back in 1999 looking at the incidence of swearing in operating theatres and found that orthopaedic surgeons out of all specialities had on average the shortest time lapse between swearing. Thought it was a funny, light hearted article displaying a common truth!

House calls: The case of the entertaining case. R Thomas.

An investigation into the hypothesis that neurology cases are more frequently used as case reports than other specialties. Apparently there is a bias amongst medical students for case reports which involve neurology. The authors looked the US programme 'House' starring Hugh Laurie and found that 28% of cases included neurological diagnoses, with infectious diseases being the 2nd most common category with 16% of diagnoses. I can't believe that to carry out this study these guys must have watched every episode of House and listed the diagnoses! Nonetheless an entertaining article.

Another topical story this week in the news has been about the recent number of cases in Scotland of patients who have been getting Anthrax poisoning as a result of contamination of heroin supplies. Apparently the story has made it all the way to the New York Times although and I did see a couple of suspected cases during the week in A&E.