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BMJ No 7129 Volume 316
Minerva Saturday 7 February 1998
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A man aged 71 was found to have a deep vein thrombosis in his
calf and was anticoagulated with warfarin. Despite this treatment he
developed recurrent pulmonary embolism. A venogram showed that he had a
duplicate inferior vena cava and he had two venal caval filters to
prevent further embolic episodes. A duplicate vena cava is relatively
common and is usually of little clinical significance; but a few cases
of pulmonary embolism have been reported. F Zavalir,
G Stewart, Submissions for this page should include the signed consent to publication from the patient |
The rapid increase in malignant melanoma in recent years has led
to a search for all potential avoidable factors. One possibility
investigated in Sweden was phototherapy for neonatal jaundice
(Archives of Pediatrics and Adolescent Medicine
1997;151:1185-8). The results showed that none of 30 children who had
developed malignant melanomas had had phototherapy, whereas 11 of the
controls had done so.
Until quite recently the diagnosis of acute appendicitis was
made on clinical grounds. Then came laparoscopy; and now the most
accurate diagnostic test seems to be helical computed tomography after
the introduction of a contrast medium into the colon. The costs and
benefits of this procedure were assessed in 100 patients with suspected
appendicitis in Boston (New England Journal of Medicine
1998;338:141-6). The scans gave an accurate verdict in 98
cases, and these results led to changes in treatment in 59 patients.
The average cost of scanning was $228 (£143) per patient, and overall
the savings made on preventing unnecessary admissions averaged $447
(£279) per patient.
Necropsies in patients with Alzheimer's disease are said to
confirm the clinical diagnosis in over 90% of cases. In reality, says
a paper in the Journal of Neurology Neurosurgery and
Psychiatry (1998;64:18-24), correcting for dual pathology and
verification bias reduces this accuracy considerably. It suggests that
in therapeutic trials based on clinical diagnosis as many as two thirds
of the patients might either not have had Alzheimer's disease at all
or might have had it and another neurological disorder. That could
easily lead to a failure to detect useful clinical benefits.
Many Western countries have recorded falls in mortality from
breast cancer in the past decade, but the causes are far from clear. A
paper in the Medical Journal of Australia
(1998;168:11-4) says that the factors that might have
contributed to the decline include changes in women's size, age at
menarche, the age and frequency of childbearing, and diet; use of
oestrogens as contraceptives and hormone replacement treatment; and
advances in treatment. The impact of mammography is still to come.
An audit in Scotland of 187 deaths after operations on the large
bowel identified an adverse event in 78 patients (British
Journal of Surgery 1998;85:80-3). Twenty six deaths were due to
an anastamotic leak; in 43 deaths the main cause was surgery being
delayed. Consultants operated on only half the patients who were
critically ill or having second or third operations. The summary
concludes that "there is a clear need for greater consultant input
with critically ill patients."
Warnings of the dangers from non-steroidal anti-inflammatory
drugs\Nsuch as gastrointestinal bleeding - should include the other side
of the risk equation, says a review in Age and Ageing
(1997;26:417-22). These drugs also seem to reduce the risk of
colorectal cancer, coronary heart disease, and Alzheimer's disease.
These are three common conditions, so that even a moderate protective
effect would suggest that a lot of lives might be saved\Nor at least
prolonged.
Are transient ischaemic attacks and minor strokes overdiagnosed
by non-specialists? A review of 508 patients referred to a hospital
clinic with these diagnoses (Quarterly Journal of Medicine
1997;90:759-63) found that neurologists agreed with the
diagnosis in only 373 patients. The other conditions diagnosed instead
included vertebrobasilar events, migraine, epilepsy, hyperventilation,
multiple sclerosis, and Parkinson's disease, and in many cases no
diagnosis could be made.
A counselling service for men who have been sexually assaulted
(SURVIVORS, 57 Mayola Road, London E5 0RE) has published data on 115
who consulted it (Archives of Sexual Behaviour
1997;26:579-88). The mean time from the assault to the consultation was
16.4 years. The assailant was known to the victim in all but 16 cases.
Deaths from abuse of solvents attract little comment, yet in
Britain between 1985 and 1991 there were 822 fatalities. An analysis of
the 775 of these deaths that could be matched to census enumeration
districts (Addiction 1997;92:1765-71) showed clear links
with social deprivation: on the Townsend deprivation index, wards with
a reported death scored an average of 2.8, whereas wards without a
death scored 0.2.
Drink driving is now so socially unacceptable that the phrase
"one for the road" has gone out of use, but it was used in a study
of volunteers in California to describe a last drink in a series
(Medicine Science and Law 1998;38:62-9). The study
showed that when a final drink was taken after the blood alcohol
concentration had started to fall it rose again and reached a fresh
peak after 18 minutes. The time taken for the peak value to be reached
was much the same for wine, beer, and spirits.
Sweeping of the membranes is sometimes used as a means of
accelerating labour. A controlled trial in Belgium (British
Journal of Obstetrics and Gynaecology 1998;105:41-4) studied
278 women, half of whom had their membranes swept at 39 weeks and every
week afterwards. No effect was seen on the average time to delivery,
but only 11% of the treated women needed induction as against 26% of
the controls.
Many British surgeons suffer from traumaphobia, says a review in
Injury (1997;28:327-30). It defines the condition as
"trepidation, apprehension, or disquietude that faces a surgeon when
asked to care for critically injured people because of inadequate
training and experience during his or her residency." Surgeons with
the disorder are likely to make comments such as "I leave trauma care
to my registrar" or "Give up trauma and develop an interest in
oncology." The problem for the future is that people can't teach
what they don't do.
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