BMJ  2004;328:E276 (28 February), doi:10.1136/bmj.328.7438.E276

BMJ USA: Minerva

Minerva

In the United Kingdom it's referred to as the "August phenomenon"; in the United States it's July. That's the time of year when the inexperience of junior doctors might be blamed for influencing patient outcomes. But in a study of what happened in 38 US intensive care units, the authors found no evidence for a problem ( Journal of General Internal Medicine 2003;18: 639-645[CrossRef][Web of Science][Medline]). The odds of death and length of stay were similar from July through September, although the stays were shorter in non-teaching hospitals.

National spending for all antidepressants increased by a whopping 600% during the 1990s, but recent evidence indicates that almost 50% of patients stop taking their medication as early as three months after starting it. A writer in Drug Benefit Trends ( 2003;15: 32-33) struggles with the issue of whether using antidepressants as placebo is good practice, while remaining concerned about the level of depression that goes undetected and undertreated.

An epidemiological study of age related hearing loss conducted between 1993 and 1995 found that 46% of people aged 48-87 had impaired hearing. Further analysis of the follow up data found that the severity of the problem was significantly associated with decreased mental and physical functioning, and quality of life in general—brought about by losing the ability to exchange information with others ( Gerontologist 2003:43: 661-668[Abstract/Free Full Text]).

There's a perception that people who survive cardiac arrests outside of hospital lead restricted and disabled lives. But the largest ever study of what happens to survivors of out of hospital cardiac arrests reveals that not only do they enjoy a good quality of life, but that bystander initiated resuscitation is strongly and independently associated with better health related quality of life ( Circulation 2003;108: 1939-1944[Abstract/Free Full Text]).

A 39 year old woman who underwent routine gynecology surgery woke up in the recovery room to find that she'd not only had her tubes tied, but she'd also lost a layer of skin from around her eyes and cheeks. Further questioning revealed that she'd started to use exfoliating agents on her face about three weeks earlier. The agents, which had been bought over the counter, contained 0.05% retinoic acid. The skin loss occurred where the anesthetist had used adhesive tape to fix the tracheal tube and to close her eyelids ( Anesthesia and Analgesia 2003;97: 1310-1311[Abstract/Free Full Text]).

Anal sphincter damage after childbirth is much more common than we think. A meta-analysis of 717 vaginal deliveries showed that 26.9% of primiparous women had anal sphincter defects and 8.5% of multiparous women had new sphincter defects. Fortunately, at least two thirds of defects caused no symptoms, although it's been calculated that the probability of fecal incontinence associated with an anal sphincter defect is about 80% ( British Journal of Surgery 2003;90: 1333-1337[CrossRef][Web of Science][Medline]).

An increasing volume of evidence suggests that even minor psychological symptoms are linked with an increased risk of death. Almost 10 000 male students at Glasgow University, UK, were interviewed between 1948 and 1968. Their temperament was assessed, and 9.7% of the total were recorded as having one or more temperament types other than "stable." Students with more than one temperament type had a higher risk of death from stroke and cancer. A label of "anxiety" was positively associated with cancer deaths and "hypomania" with an increased risk of a cardiovascular death ( Journal of Epidemiology and Community Health 2003;57: 888-892[Abstract/Free Full Text]).

Breast feeding mothers with postnatal depression are often advised not to take anti-depressants. A study in Pediatrics ( 2003;112: e425)[Abstract/Free Full Text], however, indicates that taking a selective serotonin reuptake inhibitor such as fluoxetine may be safe. All but one exclusively breast fed infant in this study showed no meaningful changes in platelet serotonin transport while their mothers were taking daily fluoxetine. It's premature to suggest treatment guidelines, say the authors, but the picture may be more gray than we thought.

Africa has a new emerging medical problem. It's ischemic heart disease, and it's clearly associated with urbanized affluent lifestyles (smoking, alcohol, sedentary living, high fat diet leading to diabetes and hypertension). A retrospective study compiling data from almost 400 African patients over a 15 year period in hospitals around Nairobi ( Nairobi Hospital Proceedings 2003;7: 178-183) underscores the fact that with "Westernization" Africans are rapidly catching up with the diseases of the West. Can Africa mount a prevention campaign successful enough to avert an epidemic of Western proportions?

"Catastrophic cheerleading injuries" is not a title to ignore. Of 39 incidents reported to the National Center for Catastrophic Sports Injury between 1982 and 2002, the authors reviewed 29. Twenty seven of the injured were women, and the rate of injuries among college cheerleaders was five times that among high schoolers. The most common injury provoking stunts were a "pyramid" and a "basket toss." The injuries included 17 severe head injuries leading to 13 skull fractures and two deaths, eight cervical fractures, and three spinal cord contusions ( American Journal of Sports Medicine 2003;31: 881-888[Abstract/Free Full Text]).

A previously fit and healthy truck driver, aged 55, was admitted to the emergency department after driving into a tree. He had scored 15 on the Glasgow coma score at the scene of the accident. He then had two grand mal seizures and was intubated. Computed tomography of his brain showed that his frontal lobe and a large portion of his parietal and temporal lobes were missing. This presumably represents a congenital anomaly that had been completely asymptomatic. It may be secondary to infarction in utero or due to a large congenital arachnoid cyst. He was extubated and made a complete recovery. Incidental findings on computed tomography are not uncommon, and abnormalities should not always be assumed to be the cause of the symptoms. Leonard Yuen senior house officer Alexander Green specialist registrar department of neurosurgery, Radcliffe Infirmary, Oxford OX2 6HE, UK

A "misery index" adds a new dimension to the US health care system. A professor of health care studies compiled the index by adding the numbers of uninsured people in the United States to figures that indicate the percentage by which the annual increases in health care costs exceed inflation. The worst year was 1960, before Medicare and Medicaid were established. The best to date was 1979, because of the high number of insured people, and lowest costs ( New York Times December 1, 2003).

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