BMJ  2003;327:309 (9 August), doi:10.1136/bmj.327.7410.309

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What's new this month in BMJ Journals

Neckties and glaucoma

Wearing a tight necktie can increase intraocular pressure by up to 20%, according to researchers from New York. Measurements were made with the subjects' shirt collars open, and three minutes after tightening their ties to a point of slight discomfort. The increase is probably due to raised venous pressure from jugular vein constriction. The implications are that an erroneous diagnosis of glaucoma might be made if tonometry is performed without the subject's tie being loosened; and that habitually wearing a buttoned collar and tight tie might predispose towards glaucomatous optic neuropathy.

Br J Ophthalmol 2003;87: 946-8[Abstract/Free Full Text]

Sciatica is not helped by epidural steroids

A randomised controlled trial in sciatica has shown no advantage for epidural corticosteroid over placebo (normal saline). After 35 days, 20 of 42 patients given three epidural injections of 2 ml of prednisolone acetate at two day intervals reported they were symptom free without need for analgesics, as did 21 of 43 who were treated similarly with saline. The authors conclude that epidural steroids were probably ineffective but could not exclude the alternative—namely, equal effectiveness of injected isotonic saline.

Ann Rheum Dis 2003;62: 639-43[Abstract/Free Full Text]

View larger version (90K): [in this window] [in a new window]   A patient presented with self limiting chest pain that had started while she was eating fish. Six days later she returned with severe chest pain, followed by a respiratory arrest. A fishbone-induced aorticoesophageal fistula was repaired and an associated mediastinal abscess was drained under bypass. She survived. Computed tomography showed a posterior mediastinal mass (A) containing free contrast (B) displacing the trachea and adjacent to the aortic arch (C). Emerg Med J 2003;20: 385-6[Abstract/Free Full Text]

Inhaled agonists help COPD

A systematic review using the Cochrane database finds that using inhaled short acting agonists for at least seven days improves lung function and decreases breathlessness and treatment failure in chronic obstructive pulmonary disease (COPD). Perhaps surprisingly, only 13 RCTs involving 237 patients met the compilers' criteria, suggesting that the widespread use of this technique arises from uncontrolled studies and clinicians' perceptions and experience. The authors call for large parallel studies of long term effectiveness and risk, whether or not patients show an acute clinical response. They are concerned that such studies are more likely to be undertaken with (more expensive) long acting agonists.

Thorax 2003;58: 580-4[Abstract/Free Full Text]

Cluster headache diagnoses delayed

A national survey of the prevalence of cluster headache (in the Netherlands) shows that the condition often remains unrecognised or misdiagnosed for many years. Despite characteristic, short lasting symptoms of very intense, unilateral orbital or temporal pain and autonomic dysfunction, only 22% of patients received a correct diagnosis at presentation. Commonest misconceptions were that episodes were due to sinusitis or dental pathology, resulting in referrals to dental and ear, nose, and throat surgeons, and to alternative practitioners. Some patients had atypical symptoms such as photophobia, phonophobia, and nausea.

J Neurol Neurosurg Psychiatry 2003;74: 1117-9[Abstract/Free Full Text]

Postmortem examination rates decline

View larger version (22K): [in this window] [in a new window]   Necropsy rates at Royal Hallamshire Hospital 1979-2001

A survey at the Royal Hallamshire Hospital, Sheffield, a major 850 bed acute unit, shows that the necropsy rate has fallen to an all time low of 13.4%. Of these, the coroner had ordered nearly three quarters for medicolegal reasons, with just 3.5% of deceased patients having a post mortem examination after a request to and consent by relatives. The authors were concerned that adverse publicity from reports of organ retention without permission, detailed after a public inquiry into procedures at the Royal Liverpool Children's Hospital, may have accelerated the rate of decline. No evidence was found for this hypothesis; the study found that few necropsies were done because doctors rarely asked for them. In 2001-2, only 6.2% of deaths resulted in a request for permission to conduct a necropsy, with nearly half being refused. Published guidelines for the process were rarely followed: house officers (interns) were most likely to make the request, rather than consultants.

J Clin Pathol 2003;56: 537-41[Abstract/Free Full Text]

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Epidural Steroids & Sciatica

Andrew D Lawson
bmj.com, 19 Aug 2003 [Full text]