Intended for healthcare professionals



BMJ 2003; 326 doi: (Published 29 May 2003) Cite this as: BMJ 2003;326:1222

Soaring caesarean section rates in the United States provide food for thought. The rate in 2001 reached an all time high of 24.4%, while that of women having a vaginal delivery after a previous section dropped to an all time low of 16.5%. An editorial in the Journal of Obstetric, Gynecologic, and Neonatal Nursing (2003;32: 283-4) asks whether this situation has arisen because the demand for perfection forces unnecessary intervention, and calls for a return to common sense guided by evidence rather than fear of litigation.


An elderly woman presented with obstructive uropathy requiring a nephrostomy. After ureteric stenting the urinary catheter bag turned purple but the nephrostomy bag remained clear. Reports suggest that the discoloration is due to a mixture of indirubin dissolved in the plastic and indigo on its surface. Organisms in the urine that possess indoxyl sulphatase activity, such as Providencia and Klebsiella, metabolise urinary indoxyl sulphate to indigo leading to purple urine bag syndrome. This is often seen with elderly patients as they have high levels of urinary indoxyl sulphate. No organism was identified in this patient, but she had cystitis without evidence of ascending infection.

Stephen G Riley, specialist registrar, Prem Thurairajah, senior house officer, Bryonie F Read, senior house officer, Kieron L Donovan, consultant, University Hospital of Wales, Cardiff CF14 4XN

Professional dancers have high rates of injuries that potentially put them out of work. A retrospective cohort study of one troupe of 42 dancers found that the introduction of “comprehensive management” (case management and intervention) reduced the number of new workers' compensation cases from 81% to 17%, and the number of days lost from work went down by 60% (American Journal of Sports Medicine 2003;31: 365-73). Other high risk occupations might benefit from similar programmes.

The person who interviewed David Lammy, the parliamentary undersecretary of state for health, for Emergency Medicine Journal (2003;20:supplement) makes an interesting observation. Lammy was the youngest member of parliament when he was elected in 2000 and is still only 30. For someone who holds such a powerful position in the NHS, it's striking that he's no older than the average hospital registrar.

Central venous lines cause two thirds of venous thromboembolic events in children, whatever their underlying condition. A prospective multicentre study of how and where central lines are put in confirmed the researchers' hypothesis that venous thromboembolic events are more frequent when central lines are inserted on the left side of the body, when they're put in the subclavian vein rather than the jugular, and when percutaneous insertion is performed rather than venous cut down (Blood 2003; 101: 4273-8).

For all those evidence based medicine enthusiasts who would no doubt think more seriously about complementary and alternative medicine if only they had the evidence, here's your chance. The UK government has recently consigned a hefty £1.3 million for research into these fields, giving priority to identifying and promoting high quality researchers. Minerva remains mindful that good research isn't just a question of funding. Many argue that conventional research methods just aren't suitable for complementary and alternative medicine.

Chlamydial infection in men may not be as devastating as it can be in women, but as it's largely asymptomatic, the implications of having it and passing it on unawares are critical. Recent prevalence figures (Lancet 2003;361: 1792) indicate that nearly 10% of men could be infected, and 90% of these were asymptomatic. Although the men studied were young army recruits, they were “no more sexually active than the average young male population.”

Tension-free vaginal tape is said to offer specific advantages to women with genuine stress urinary incontinence. But the technique involves passing a needle and has caused major vessel injury. Using 10 cadavers to explore why this happens, gynaecologists found that the major vessels lie 0.9-6.7 cm lateral to the needles. If the needle is aimed laterally, or rotated, major injuries can occur (Obstetrics and Gynecology 2003;101: 933-6).

Patients who return home from a tropical country with a fever can cause problems to even the most astute diagnostician. A prospective observational study of febrile children admitted to hospital who had visited the tropics sometime in the preceding year found that they often have a treatable infection. The most helpful investigations were a full blood count, malarial film, stool and blood culture, and a chest x ray (Archives of Disease in Childhood 2003;88: 432-4).

People with Crohn's disease often need multiple surgical procedures, so it's important to know how quality of life is affected by surgery. A study looking at the immediate postoperative period found that quality of life measures improved greatly within the first 30 days. Women and patients who had no postoperative complications reported higher scores than other patients. Scores were not affected by the type of surgical procedure or by the nature of the disease (Journal of the American College of Surgeons 2003;196: 714-21).

Why do some people feel hotness more than others? Sensory neurons are triggered by specific receptors. Normally, these receptors are held on “pause” by a lipid molecule called PIP2, but burning substances such as capsaicin cut PIP2 loose, sensitising the neurons. Scientists have identified the binding site for PIP2, and they say that if genetic, biochemical, or pharmacological means can modify the site, then neuronal sensitivity may be influenced (Science 2003;300: 1284-8).

Some people with acid reflux are also prone to reflux associated laryngitis (RAL). But does treatment for reflux have any impact on the laryngitis? A placebo controlled crossover trial of a protein pump inhibitor shows that in non-smokers the condition is self limiting, and laryngitis tends to improve even if the reflux persists. Treatment helps the acute symptoms of laryngitis, but the authors conclude that the advantages of long term treatment over placebo are overstated (Scandinavian Journal of Gastroenterology 2003;38: 462-7).

In 2002, 32 countries used mass drug administration to stop transmission of lymphatic filariasis. Almost 55 million people were treated with a combination of albendazole and diethylcarbamazine or ivermectin, more than twice the number reached in 2001. A further 36 million received diethylcarbamazine alone. This sounds a lot, but it's a drop in the ocean of the one billion targeted worldwide (Weekly Epidemiological Record 2003;78: 171-9).

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