BMJ  2004;328:856 (10 April), doi:10.1136/bmj.328.7444.856

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What's new this month in BMJ Journals

Adults can be victims of Munchausen syndrome by proxy

Australian investigators report that a 71 year old man with a 16 year history of recurrent episodes of stupor and coma often required intubation and ventilation before he spontaneously recovered over 12-36 hours. The episodes were usually provoked by stressful events. Extensive investigation at several hospitals was unhelpful, but after a rapid response to intravenous flumazenil he was diagnosed as having "endogenous endozepine-4 stupor." Seven years later his wife confessed to surreptitiously giving lorazepam to her mother after a stroke. She then admitted to having periodically laced her husband's food and drink with oxazepam and lorazepam. The doctors admitted that they were confounded by a diagnosis of Munchausen syndrome by proxy in the wife of a pleasant elderly country gentleman.

J Neurol Neurosurg Psychiatr 2004;75: 368-9[Abstract/Free Full Text]

Telephone resuscitation? Easier said than done

An analysis of 100 cardiac arrest patients actively resuscitated by London Ambulance Service crews concludes that there are many barriers to successful resuscitation under telephone instruction before they arrive. Half of all events were hampered by the caller thinking that the patient could not be resuscitated; not wanting to undertake cardiopulmonary resuscitation; being a third party; or having language problems. Where there was a barrier, mean time to recognition of arrest was 90 seconds, time to first ventilation 6 minutes, and time to first cardiac compression over 7 minutes. With no barrier, times were 20 seconds, 2 minutes, and just over 3 minutes respectively. Aware of many bystanders' apprehension about conducting mouth to mouth ventilation, the authors speculate on the possible implications of advising a compression-only approach.

Emerg Med J 2004;21: 233-4[Abstract/Free Full Text]

Claims of negligence in primary care highlight appendicitis

Peer review of malpractice (clinical negligence) claims against primary care doctors in the United States shows a disproportionate risk in some conditions, including appendicitis, when data are adjusted for consultation rates. Peer reviewers examined more than half of the 49 345 claims processed by the Physician Insurers' Association of America between 1985 and 2000. They concluded that negligence had occurred in 86% of cases where payment had been made and 14% where it had not. Among those the reviewers judged non-negligent, 7% had had a payout. The most common single diagnostic category was acute myocardial infarction (5% of all claims), but when consultation rates were factored in, appendicitis assumed a relative risk seven times greater. The next greatest risk was brain damaged infants (UK primary care doctors are unlikely to be involved in such cases). Contributing factors included problems with records and poor communication between doctors, which figured highly in claims for death or severe injury.

Qual Saf Health Care 2004;13: 121-6[Abstract/Free Full Text]

A reason for caution with the Euro After the conversion to the Euro in January 2002, Greek doctors noted that inhalation and ingestion of coins by children increased nearly threefold. During the same period, Danish children—who were not exposed to a change in currency—maintained their previous rate. The European 10 cent coin is much smaller than its preceding counterpart in Greece, the 20 drachma. Researchers recommend further studies of the relation between coin design and ingestion or inhalation, commending the Scandinavian habit of drilling a hole in smaller coins to prevent airflow obstruction in the event of choking. Arch Dis Child 2004;89: 382-3[Free Full Text]

A 16 year old boy frequently swallowed razor blades, which were then removed by endoscopy. On the reported occasion the disposable razor blades were seen in the stomach, but by the time removal was attempted the blades had progressed into the small bowel, beyond the reach of a standard endoscope. All were passed spontaneously per rectum, confirming the impression that inert foreign bodies are probably safe once they have traversed the pylorus. Gut 2004;53: 477[Free Full Text]

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