Minerva

From BMJ USA 2002;Dec:698

It's easy to blame patients for not taking their medicines as directed, but an extraordinarily high number of medication errors seem to be made by hospital staff too. In 36 institutions in one American study, 19% of doses given were considered "in error." The most common errors were wrong time (43%), omission (30%), wrong dose (17%), and unauthorized drug (4%). Fortunately only 7% of the errors were judged potential adverse events (Archives of Internal Medicine 2002;162:1897-1903)[Abstract/Free Full Text].

Minerva wonders if the long term prognosis for doctors who misuse alcohol is any different from anyone else with the same problem. A 21 year follow up of 100 alcoholic doctors found that 24 had died directly from their alcoholism, 73% considered themselves recovered alcoholics, and 9% had developed oral, throat, or esophageal cancer. Of the 56 who are still alive, 29 have retired and 27 are still working as doctors (Alcoholism 2002;37:370-374).

A tenth of patients with dyspepsia present with alarm symptoms. But although alarm symptoms are said to predict a bad prognosis, a three year prospective study found they gave low positive predictive values and high negative predictive values. The authors say this reflects the low incidence of cancer and ulcers in the general population. Rather depressingly, most of those who did develop cancer or ulcers did not present with alarm symptoms at the initial consultation (Scandinavian Journal of Gastroenterology 2002;37:999-1007)[CrossRef][ISI][Medline].

The hygiene hypothesis proposes that declining exposure to infections is linked to the rising trend in asthma and allergy. Analysis of a huge population database in the United States supports the relation (Journal of Allergy and Clinical Immunology 2002;110:381-387)[CrossRef][ISI][Medline]. Data from the third National Health and Nutrition Examination Survey show that serological evidence of certain infectionsmostly foodborneis associated with a lower probability of suffering from hay fever and asthma.

The contribution that neurologists can make to patients with chronic back pain seems limited, according to a study in European Neurology (2002;48:61-64)[Medline]. Of 97 new patients seen over two years in one neurology clinic, two thirds had non-neurological conditions and were given treatment for their symptomsas were those who fell into the neurological group. As pain clinics or surgical teams offer specialist pain management, and the rest can be overseen within primary care, the neurologist's input seems at best "symbolic."

Three quarters of the 3000 British veterans of the Gulf war seeking advice up to June 2001 from a special medical assessment program were classified as being "well." Of these, 10% were completely symptom free, and the rest had medical diagnoses expected in the age group seen. Of those who were judged unwell, most had post-traumatic stress disorder (Journal of the Royal Society of Medicine 2002;95:491-497)[Abstract/Free Full Text].

Another contentious condition for which there is a wide range of opinion about the amount of disability suffered is whiplash injuries. They're also highly associated with claims for legal compensation. A large retrospective study of claimants found that the vast majority of them had a favorable outcome, with few neurological findings and very small restrictions in mobility 32 months later. On the basis of these findings, the authors suggest that the initial x rays taken in the emergency room are probably the only routine imaging needed (Injury 2002;33:569-573)[Medline].

As seasonal colds and viruses hover on the horizon, and patients start the autumnal braying of "Is there something going around?" it's sobering to read about the burden of influenza. A French prospective study conducted during the winter of 2000 found that in a third of households that contacted a doctor with flu-type symptoms, a secondary case of clinical influenza developed. Of these secondary cases, 43% did not consult with a doctor. The average length of illness was eight days, and the average number of lost work days was four (Archives of Internal Medicine 2002;162:1842-1848)[Abstract/Free Full Text].

Minerva sometimes finds moldy cheese at the back of her fridge, so she was fascinated by an account of 2000 year old cheese discovered in Herculaneum, which has been found to contain a variety of bacteria, including possibly Lactobacillus and Brucella. This fits with the skeletal signs of brucellosis observed in people fleeing from the eruption of Vesuvius. Accurate molecular identification is impossible because of the length of time the cheese has lain under mud and the high temperatures experienced (Journal of Infection 2002;45:122-127).

View larger version (70K): [in this window] [in a new window]   A 17 year old Zambian girl with sickle cell disease presented to our mission hospital with gross nasal collapse and foul smelling nasal discharge of several months' duration. Bone infarction is a common complication of all serious sickling disorders. Aseptic necrosis of the femoral and humeral heads is most frequently seen, which can lead to gross deformity of the affected joint. Large bone infarcts may become secondarily infected with various bacteria, including salmonellae, resulting in osteomyelitis. Unusually, this girl developed chronic osteomyelitis of her nasal bridge. The foul smelling discharge responded only temporarily to antibiotics, and she required surgical debridement and sequestrectomy to remove the infected bone. D Elphick, specialist physician, H Elphick, specialist physician, St Francis Hospital, Katete, Zambia

A weighty review in the American Journal of Clinical Nutrition (2002;76:743-749)[Abstract/Free Full Text] concludes that waist circumference is at least as strong as body mass index in predicting cardiovascular disease risk. Having a body mass index over 25 makes us overweight, while one over 30 renders us obese. The equivalent cut-off values for waist circumference are 35 inches in men and 33 inches in women for being overweight, and 39 inches in men and 37 inches in women for obesity.

Taking too many painkillers can lead to "medication overuse headaches." A German study found that the average length of time of taking painkillers before these headaches start is shortest for the triptans (5-HT1 agonists) (1.7 years), longer for ergots (2.7 years), and longest for ordinary painkillers (4.8 years). Triptans caused migraine-type headaches, whereas ordinary analgesics caused tension-type headaches (Neurology 2002;59:1011-1014)[Abstract/Free Full Text].

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