Emergency care for older patients and other stories . . .BMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f5576 (Published 19 September 2013) Cite this as: BMJ 2013;347:f5576
The secretary of state for health for England, Jeremy Hunt, recently spoke of older patients who are more familiar with the doctors in their local emergency department than with their own general practitioners. A good place to start looking for them, thought Minerva, would be in the Tower Hamlets district of London, with its high levels of deprivation and large immigrant communities. A survey in the Emergency Medicine Journal (2013, doi:10.1136/emermed-2013-202845) compared the ages of patients and reasons for attendance between emergency departments in that area and local general practices, out of hours clinics, or walk-in centres. In a random sample of 384 patients who presented to the emergency department, only eight were over the age of 75 years: the mean age was 35. Judging from case mix figures, use of the various emergency facilities seemed largely appropriate. Perhaps the health minister’s patients live elsewhere. The search must go on.
“I went to the doctor with a problem, I came out with a disease,” said Groucho Marx. Chances are his doctor had sent him for tests. A valuable discussion paper in BMJ Quality and Safety (2013, doi:10.1136/bmjqs-2012-001621) identifies five ways by which testing can lead to misdiagnosis: an inappropriate test is ordered; an appropriate test is not ordered; an appropriate test result is misapplied; an appropriate test is ordered, but a delay occurs somewhere in the total testing process; and the result of an appropriately ordered test is wrong. Marx himself was aware of the limitations of diagnostic testing, declaring in Monkey Business: “Either this man is dead or my watch has stopped.”
Diagnosis is fundamentally a process of labelling, in the belief that the label will be a guide to appropriate treatment, or at least lead to a better understanding of the disease process and its prognosis. But many diagnostic labels obstruct rather than help. Polycystic ovary syndrome is a good example, as discussed in the Journal of Clinical Endocrinology and Metabolism (2013, doi:10.1210/jc.2013-2040). The authors propose a “two-state solution”: keep the “polycystic ovary syndrome” label for patients whose main problem is limited to ovarian morphology, and come up with another name for those with hyperandrogenism and chronic anovulation. But fearing the baleful effects of labelling, the authors do not actually suggest the new name.
High density lipoprotein cholesterol is a strong predictor of reduced cardiovascular mortality in the general population, and drugs to increase high density lipoprotein cholesterol have been seen as potential successors to statins—which have been huge profit makers for the pharmaceutical industry. But none developed so far has shown any protective effect. And a new study shows that it is extremely unlikely that raising high density lipoprotein cholesterol will ever be a viable approach to secondary prevention in established coronary artery disease. The LUdwigshafen RIsk and Cardiovascular health (LURIC) study provides 10 year follow-up data for 699 people without coronary artery disease, 1515 with stable coronary artery disease, and 927 with unstable coronary artery disease (European Heart Journal 2013, doi:10.1093/eurheartj/eht343). In this and two other cohorts, there was no relation between levels of high density lipoprotein cholesterol and cardiovascular mortality in those with established coronary artery disease.
Travellers from Europe to magical destinations in south and South East Asia often risk disruption of their pleasures by diarrhoea. Rifaximin taken for three days can be an effective treatment for the many enteroinvasive and antibiotic resistant bacteria that cause travellers’ diarrhoea in those parts of the world. But Minerva wonders if this will remain the case if this antibiotic is widely used for prophylaxis. A double blind trial allocated 258 travellers from Tübingen, Germany, to take either 200 mg of rifaximin twice daily or placebo for the whole of their oriental travels (Lancet Infectious Diseases 2013, doi:10.1016/S1473-3099(13)70221-4). Rifaximin reduced the rate of diarrhoeal illness from 1.99 to 1.04 per 100 days, giving a number needed to treat of 5.7.
Some intrepid travellers also run the risk of envenomation by snakes, insects, or spiders, which if not fatal can be extremely painful. Yet the poisons that are so good at stimulating pain receptors might also lead to better ways of blocking them, according to a review in the British Journal of Pain (2013, doi:10.1177/2049463713502005), with the title “Venom: the sharp end of pain therapeutics.” The authors—who work for Venomtech, a company in the Kent Enterprise Hub at the University of Kent, Canterbury—wax enthusiastic: “The last 12 months have seen dramatic discoveries of analgesic tools within venoms. Spiders, snakes and even centipedes are yielding peptides with immense therapeutic potential.” They even coin a new name for their discipline: venomics.
Cite this as: BMJ 2013;347:f5576
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