BMJ No 7121 Volume 315
Minerva Saturday 6 December 1997
| A man aged 38 came to the accident and emergency department
having been in a fight and further assaulted by his opponent's mother,
who was wielding a golf club. He had not lost consciousness. The skull
radiograph was reported as showing an extensive fracture around the
pterion with fragmentation of the frontozygomatic process. Spiral
computed tomography with subsequent three dimensional reconstruction
showed that the frontozygomatic process was intact but that owing to
the angle of the skull x ray the pterional fracture had
altered the appearance of the margin of the orbit. Thus maxillofacial
exploration was avoided and the patient was observed on a neurosurgical
ward. He recovered well.
| |
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Two large clinical trials of the effects of implanted
defibrillators on mortality, one positive, one negative, appeared in
the New England Journal of Medicine (1997;337:1569-83).
Commenting on the results in an editorial (1621-3), the journal says
that the clinical settings in which a defibrillator is clearly valuable
are still a minority: fewer than a tenth of potential victims of sudden
death come within the remit of recent trials, so much more research
needs to be done. Several other trials of defibrillators "have
remained remarkably silent," possibly because the results are
disappointing, yet research of this kind is the only way forward in the
era of evidence based medicine.
Two proteins that give gliomas their unique invasiveness have
been identified by research teams in the United States (Science
1997;278:1226). Gliomas have a dreadful prognosis; most
patients are dead within two years of diagnosis. The hope is that
treatment directed against these invasive proteins might alter the
picture.
Automated haematological analysers may give misleading data in
some circumstances, warns a report in the Journal of Clinical
Pathology (1997;50:967-9). A patient with hepatitis C had an
automated blood count in which the electrical impedance method was
used. This showed an abnormal leucocyte differential, with 0.3%
eosinophils. On direct inspection of the blood film with manual
counting the proportion was 50% - admittedly with fewer eosinophil
granules than usual. The message is that a blood film should be
examined whenever the cell counts reported by an automated analyser
seem abnormal.
Between 1974 and 1994 two surgeons in Leicester carried
out 37 operations to relieve compression in the thoracic outlet
(Journal of the Royal College of Surgeons of
Edinburgh 1997;42:319-23). The average age of the
patients was 37; 29 had predominantly neurological and 8 predominantly
vascular symptoms. The most common operation was removal of a cervical
rib, but some patients had a first rib removed too. Of the 29 patients
who responded to a questionnaire, 27 thought the operation had been
worthwhile, though 14 had some persistent pain.
Why do we hiccup?, asks a commentary in Gut
(1997;41:712-3). The answer offered by the authors from Chicago is that
hiccuping is a programmed isometric exercise of the inspiratory
muscles, which are superfluous in utero but have no time for maturation
after birth. Later in life the hiccup is a vestigial reflex.
Minimally invasive cardiac bypass surgery "is converting an
operation that should be routinely safe into a hair raising
adventure," according to John J Collins Jr, professor of surgery at
Harvard Medical School (Circulation 1997;96:2483-4). A
consensus seems to be emerging that the advantages of doing away with
the heart-lung machine - savings in cost and hospital stay - may not be
enough to balance the lower effectiveness of the minimally invasive
approach.
Of 7205 sudden, unexpected deaths referred to the forensic
medicine unit of the University of Edinburgh, 164 were found to be due
to rupture of abdominal aortic aneurysms (Journal of Clinical
Forensic Medicine 1997;4:111-6). Further analysis showed that
in 117 cases the people had been seen by their doctors within the 18
months before their deaths. This treatable condition is still being
overlooked even when typical symptoms such as back pain are present.
Post-traumatic stress disorder was first described in 1981, and
since then various studies have found rates of from 1% to 46% after
violent, upsetting incidents related to accidents, occupational
injuries, and sporting activities (Journal of Accident and
Emergency Medicine 1997;14:366-9). No clear consensus has
emerged on how the physical effects of injury interact with
psychological and social factors, and the picture has been further
obscured by the large numbers of legal claims for compensation being
made by accident victims.
Paramedics taught to interpret electrocardiograms can
reliably diagnose myocardial infarction (Heart
1997;78:456-61). In a prospective controlled study in Derby in
247 patients the interval between the telephone call and thrombolysis
was reduced from 154 to 93 minutes. Previous research had suggested
that initiating thrombolysis 60 minutes earlier would save 23 extra
lives in every 1000 patients treated.
Albucasis, the Arabian "prince of surgeons," was born in the
year 936, and his textbook of medicine was an authority for 500 years
(The American Surgeon 1997;63:1027-8). He introduced the
ant closure technique for intestinal repairs: ants were encouraged to
bite the everted, approximated edges of the bowel and then decapitated.
The formic acid in the ants' mouths acted as an antiseptic.
A follow up for three years of 111 women treated for
stress incontinence by paraurethral injections of collagen is
reported in the British Journal of Urology
(1997;80:757-61). One quarter said that they were dry and a further two
fifths said that their condition had improved. The results seemed not
to be influenced by previous surgery for incontinence.
The proportion of American citizens with diabetes mellitus is
now 3%, a 17% increase since 1980 (Morbidity and Mortality
Weekly Report 1997;46:1014-8). The rate is much higher in black
people - now 5.4%, an increase of 37% since 1980. The annual total of
new cases diagnosed each year is now over 700 000.
"Gloomy weather," people say to Minerva at this time
of year, but the dark clouds don't seem to increase the risk of
suicide. Research in Cheshire (British Journal of Psychiatry
1997;170:473-7) has shown that deaths from self harm were most
common during fine, bright weather, with little fluctuation throughout
the months of the year.
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