Minerva

Tennis elbow and other stories . . .

BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g2283 (Published 26 March 2014) Cite this as: BMJ 2014;348:g2283

Five hospitals in southwest London cater for 15% of England’s children. A remarkable survey from these centres (Archives of Disease in Childhood 2014, doi:10.1136/archdischild-2013-305565) identifies a whole list of paradoxes. Admission rates are climbing, but serious bacterial infections are becoming rare, occurring in only 2.4% of children admitted to hospital for suspected infection. Two thirds of these children had pre-existing comorbidity. So although the UK still has a relatively high death rate from childhood infection, and both doctors and parents are more vigilant than ever, in absolute terms the risk of a child dying from infection has never been so small. The yield of serious infections confirmed by blood or cerebrospinal fluid culture in previously healthy children admitted to hospital was just 1.1%.

Minerva is impressed by surgeons who subject the mysteries of their craft to the cold light of scientific enquiry. But she thinks the world should be even more grateful to the patients who consent to undergo surgery knowing there is a 50/50 chance that it will be a sham. Such was the fate of 74 people who had previous Roux-en-Y gastric bypass surgery but wanted to lose more weight. This was to be achieved by laparoscopic surgery using the StomaphyX device, aiming for a reduction in pre-Roux-en-Y bypass excess weight of 15% or more in the first year (JAMA Surgery 2014, doi:10.1001/jamasurg.2013.4051). But when it became clear that this endpoint would not be achieved in at least half of the StomaphyX patients, the trial was halted.

Arthritis mutilans is the rather cruel name once used for the most severe form of psoriatic arthropathy. Most kinds of arthritis that occur in around a third of people with psoriasis are much less destructive. But such patients still need to be referred for early treatment, as shown by a study of the records of 283 patients in the rheumatology clinic of St Vincent’s University Hospital, Dublin (Annals of the Rheumatic Diseases 2014, doi:10.1136/annrheumdis-2013-204858). The analysis showed that even a six month delay from symptom onset to the first visit to a rheumatologist contributes to the development of peripheral joint erosions and worse long term physical function. The median time from disease onset to the first rheumatological assessment was exactly twice that.

Tennis elbow—chronic lateral epicondylitis—is only occasionally caused by playing tennis. However, if you play tennis for a living you have a 50% chance of getting it at some point, and this is no doubt the reason why a systematic review of platelet-rich plasma injections for the condition appears in the British Journal of Sports Medicine (2014, doi:10.1136/bjsports-2013-093281). A review of six trials shows that these definitely do no good but are less harmful than corticosteroid injections. Look out for the headline “Andy Murray off with elbow: docs advise nothing.”

Ondansetron was for many years a big earner for GlaxoSmithKline, although its price meant that for years it was kept as a last resort for alleviating nausea and vomiting caused by cancer chemotherapy, radiotherapy, and surgery. But in one of those upheavals of medical fashion that Minerva finds hard to understand, it is now hugely popular in emergency departments for the treatment of children’s gastroenteritis, although it has never undergone proper trials for this indication. A trawl through the Pediatric Health Information System administrative database in the US (JAMA Pediatrics 2014, doi:10.1001/jamapediatrics.2013.4906) shows that oral ondansetron use increased from a median institutional rate of 0.11% of visits for gastroenteritis in patients aged 0-18 years in 2002 to 42.2% in 2011. Yet there was no fall in the number of children admitted for intravenous rehydration. Why do doctors still demand no evidence for their medicine?

Desperate remedies make for uncomfortable reading. Imagine having a tube passed into your bronchi to heat them up to 60°C. Minerva’s asthma would have to be pretty severe and persistent for her to submit to that, but the trials examined in a new Cochrane review also included adults with moderate asthma (Cochrane Library 2014, doi:10.1002/14651858.CD009910.pub2). The brave souls who submitted were more likely to be admitted to hospital in the short term, and a bit less likely to get asthma attacks in the longer term. Not very hot results.

A little learning is a dangerous thing, but a lot of learning will help you to hide Alzheimer’s disease. At least that’s Minerva’s take on a recent study in Brain (2014, doi:10.1093/brain/awu035), which describes the PAQUID cohort study. Highly educated people showed a much longer lag time between the onset of subtle cognitive impairment and overt dementia than did less educated ones. But in this study from Bordeaux, adjustment does not seem to have been made for the effect of drinking better claret.

Notes

Cite this as: BMJ 2014;348:g2283

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