BMJ  2005;330:798 (2 April), doi:10.1136/bmj.330.7494.798

Minerva

Floating in its lagoon of amniotic fluid, the fetus is well protected from most types of trauma. Motor vehicle crashes are an exception. A study from Washington state found an increased risk of adverse pregnancy outcomes even when the mother had no apparent injury ( American Journal of Epidemiology 2005161 : 503-10[Abstract/Free Full Text]). Preterm labour and placental abruption were the commonest problems—perhaps because the shear forces at impact caused the placenta to separate from the uterus.

An editorial in the British Journal of Anaesthesia ( 2005;94: 413-6)[Free Full Text] celebrates rightly, if slightly belatedly, the 50th birthday of the longest running and arguably the most successful audit in medical history: the Confidential Enquiry into Maternal Deaths. It first reported in 1957 and has updated its findings regularly ever since. It must have saved the lives of many women. The latest report can be found at www.cemach.org.uk/

Opaque terminology and weasel words get in the way of plain talk and thought. The terms we use to discuss medical errors and patient safety are no exception. Despite their name, "serious reportable events" often remain unreported. A taxonomy is proposed which does away with adverse events, near misses, and close calls in favour of an inclusive classification schema based on notions of impact, type, domain, cause, prevention, and mitigation ( International Journal for Quality in Health Care 2005;17: 95-105).

Staphylococcus epidermidis, usually a benign commensal, becomes life threatening when it colonises prosthetic heart valves and other indwelling medical devices. The reason why the organism becomes pathogenic once it circumvents the protective barrier of the skin is becoming clearer ( Journal of Clinical Investigation 2005;115: 688-94[CrossRef][ISI][Medline]). S epidermidis secretes an extracellular polymer (poly--DL-glutamic acid) that forms a biofilm protecting it from the host's innate defences. This polymer is a promising target for drug development aimed at combating these infections.

Alendronate is widely used in the treatment of osteoporosis. It works by inhibiting bone resorption. But a report in the Journal of Clinical Endocrinology and Metabolism ( 2005;90: 1294-301)[Abstract/Free Full Text] suggests that you can have too much of a good thing. Of nine patients being treated with alendronate who sustained spontaneous non-spinal fractures, in six healing was delayed or absent for up to two years. Biopsies showed striking suppression of new bone formation.

A diagnosis of schizophrenia is an automatic exclusion criterion for heart transplant in most transplant programmes worldwide. People with schizophrenia are supposed to be at high risk of worsening psychosis either because of the need for steroids or because of the emotional difficulties arising from accepting an organ from another person. They are also thought to be unlikely to cope with the rigours of postoperative follow-up. The authors of a report of a successful heart transplant in a man with schizophrenia point out a lack of data in support of any of these assumptions and encourage psychiatrists to take a lead in changing the practice of discrimination against people with psychotic disorders ( American Journal of Psychiatry 2005;162: 453-7[Free Full Text]).

Minerva has often wondered privately if the level of concern about the epidemic of obesity in children might not have reached the verge of hysteria. So she was pleased to see a thoughtful discussion of the potentially negative consequences of interventions to prevent obesity in Health Education Research ( 2005;20: 259-65)[Free Full Text]. Being the right weight is only one part of child health, yet it dominates current health promotion initiatives aimed at young people.

Neurologists and psychiatrists occasionally encounter patients with loss of vision who describe recurring complex visual hallucinations, usually of people or animals. This syndrome is named after a Genoese philosopher, Charles Bonnet, who, in 1769, described the visual hallucinatory experiences of his cognitively intact but visually impaired grandfather. It seems that Charles Bonnet syndrome is actually quite common. When a series of patients with visual loss were asked specifically about hallucinations, over half admitted to experiencing them ( Archives of Ophthalmology 2005;123: 349-55[Abstract/Free Full Text]). They hadn't mentioned them before because of anxiety that they might be thought mentally ill. Treatment requires no more than reassurance.

Babies and young children who don't sleep drive their parents to despair and to paediatricians. Data from the Quebec longitudinal study of child development show, perhaps not very surprisingly, that the answer lies in the way parents behave at bedtime. The report ( Archives of Pediatric and Adolescent Medicine 2005;159: 242-9[Abstract/Free Full Text]) is careful not to claim causation, but it did find that young children whose parents lulled them to sleep and stayed until they dropped off were less likely to sleep six hours at a stretch than were children who were left to fall asleep on their own.

A 47 year old man presented with a 10 day history of left sided headache and conjunctival injection. His local doctor had noticed a left Horner's syndrome and thought he might have a Pancoast tumour. The patient works outdoors in the tropics and had also noticed that his felt hat, which normally became soaked with sweat at work, had remained dry on the left side. A clinical diagnosis of carotid artery dissection was made. Results on initial computer tomography with contrast were reported as normal, but a magnetic resonance angiogram confirmed the diagnosis. He was treated with hypotensive drugs and anticoagulants and had no neurological sequelae. He remains well seven years later, with a persistent left Horner's syndrome and lack of sweating on the left side of his head. Graham Simpson, director, department of thoracic medicine, Cairns Base Hospital, Cairns 4870, Australia

 

Increasing use of fertility drugs is almost certainly the main cause of the recent increase in dizygotic twinning in most developed countries. But a reanalysis of data on more than 50 000 pregnancies from the collaborative perinatal project, which took place in the United States in the early 1960s, before the use of fertility drugs was widespread, shows that the mother's size also has an influence ( Obstetrics and Gynecology 2005;105: 593-7[Abstract/Free Full Text]). Women whose body mass index was greater than 30 were twice as likely to have twin pregnancies as women whose body mass index was less than 20. Twinning was also commoner in taller women.

A longitudinal study of women who experienced a bipolar affective psychosis in the puerperium shows that the risk of recurrence in subsequent pregnancies is high. However, avoiding further pregnancies is no guarantee of remaining well. Over 60% of the women in the study suffered a non-puerperal relapse during a mean follow-up of nine years ( British Journal of Psychiatry 2005;186: 258-9[Abstract/Free Full Text]).

---

Guidance at bmj.com/advice

CiteULike    Complore    Connotea    Del.icio.us    Digg    Reddit    Technorati    What's this?

Rapid Responses:

Read all Rapid Responses

Swiss Philosopher and Genova

Casimiro Cabrera Abreu
bmj.com, 4 Apr 2005 [Full text]