BMJ 2009; 338 doi: http://dx.doi.org/10.1136/bmj.b1585 (Published 20 April 2009) Cite this as: BMJ 2009;338:b1585

Do patients with Parkinson’s disease often become compulsive gamblers or nymphomaniacs? Such extreme behaviours can be provoked by the drugs taken for Parkinson’s, but the frequency with which this occurs and the temporal relation with use of the drugs are unknown. A retrospective study of 267 patients found that seven had documented new onset gambling or hypersexuality. All seven were taking a therapeutic dose of a dopamine agonist. In five of the seven patients the new behaviour was pathological and disabling, and two had been seen by a psychiatrist before the connection with dopamine agonists was recognised (Mayo Clinic Proceedings 2009;84:310-6, doi:10.4065/84.4.310).

Fatal opioid overdoses can be avoided if naloxone is given quickly enough. A US programme, started in 2006, which taught bystanders to administer naloxone as an intranasal spray reports that after 15 months, 74 overdoses had been successfully reversed by 385 bystanders, and that few problems were encountered (American Journal of Public Health 2009;99:788-91, doi:10.2105/AJPH.2008.146647). Minerva assumes that shoving a spray up someone’s unconscious nose without invitation meets with little resistance.

Another potential cause of fatality is long term nasogastric intubation. A case report in the Journal of the Royal Society of Medicine (2009;102:157-9, doi:10.1258/jrsm.2009.080395) describes how prolonged nasogastric feeding in a patient originally admitted with a perforated duodenal ulcer led to an acute gastrointestinal bleed and haemodynamic instability. The patient didn’t eat because she became depressed and consequently needed nutritional support. The near fatal bleed was found to be caused by a tube-associated inflammatory oesophageal stricture and focal gastritis with ulceration. The duodenal ulcer was virtually healed at the time of the bleed.

From noses to ears. A morality tale in Casebook (January 2009, www.medicalprotection.org/uk/casebook-january-2009/case-reports/turning-a-deaf-ear) describes how a 12 year old girl visited her GP surgery recurrently over eight weeks with a continuing bloody discharge from her right ear. She had swabs taken, and the correct antibiotics were prescribed. At no point, however, did any of the doctors who saw her record anything about having seen the eardrum, or having asked about hearing deficits. By the time she was referred to a specialist and sent for an urgent scan, surgery was needed for the cholesteatoma which had not been detected earlier. She sustained permanent hearing loss.

Anger suppression should carry a health warning. In patients with heart disease, for example, anger suppression is associated with poor quality sleep. Expression of anger was assessed with a validated scale in 1020 patients recruited from the Heart and Soul Study. Adjusting for confounding factors, the multivariate analysis found that as “anger-in” increased, so did the poor quality of sleep. As “anger-out” increased, the quality of sleep improved. What’s not known is whether modifying anger expression can improve the quality of sleep or indeed reduce cardiovascular morbidity and mortality (Psychosomatic Medicine 2009;71:280-5, doi:10.1097/PSY.0b013e31819b6a08).

What’s the best way to sample peripheral nerves—with a skin biopsy or a suction skin “blister”? The blister is a less invasive but reliable method that allows visualisation and quantification of the epidermal nerve fibres. The “roof” of the blister provides a bird’s eye view of all the epidermal nerve fibres in one tissue specimen. A study of two 3 mm suction blister specimens and one 3 mm punch biopsy specimen from 25 healthy volunteers without known peripheral neuropathy found no systematic differences in nerve density between the two different types of samples (Neurology 2009;72:1205-10, doi:10.1212/01.wnl.0000340984.74563.1c).

Percutaneous surgical closure of atrial septal defects is commonly done in childhood, and the results are generally good. But less is known about the long term outcomes of this type of intervention in older people. A study of almost 100 adults aged over 60 found that overall the procedure is safe in these patients, and that the “profit” can be measured in symptom reduction, improvement of exercise capacity, and right-heart remodelling—but 16 patients of 96 experienced paroxysmal atrial fibrillation after closure (Circulation— cardiovascular interventions 2009;2:85-9, doi:10.1161/circinterventions.108.814046).

Conventional anaesthetics are toxic to muscle and nerve cells, so attempts to formulate long acting or slow release local anaesthetics have mostly been thwarted. Now scientists have tested an anaesthetic called saxitoxin, encapsulated in liposomes, in rats and found it very effective, especially if partnered with dexamethasone, which enhances the action of encapsulated anaesthetics. On its own one liposome formulation provided nerve block for 48 hours without toxic side effects. With the addition of dexamethasone, the block lasted seven days (Proceedings of the National Academy of Sciences 2009; published online 13 April, doi:10.1073/pnas.0900598106).

How much pleural fluid is needed to perform an adequate diagnosis of malignant disease? The answer, according to a prospective study of patients undergoing diagnostic thoracocentesis, is not as much as you might think. In all 23 patients with a malignant pleural effusion, the 50 ml specimen and the large volume specimen (around 800 ml) were cytologically identical. This was also the case in the 21 patients with negative pleural cytology findings. Diagnostic yield is not increased by tapping more than 50 ml of pleural fluid for cytology (Chest 2009;135:999-1001, doi:10.1378/chest.08-2002).

A large Dutch study says that low risk, planned home births are as safe as planned hospital births. The babies of women who had planned a home birth were equally likely to be admitted into a neonatal intensive care unit as those of women who had planned hospital births, and the perinatal mortality rate was the same in both groups. Before everyone jumps for home births, however, it should be remembered that the Netherlands is prepared to meet the demand for home births, which is not necessarily the case in other countries (BJOG 2009; doi:10.1111/j.1471-0528.2009.02175.x).


Cite this as: BMJ 2009;338:b1585

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