Intended for healthcare professionals

Minerva

Surgical checklists and other stories . . .

BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g1693 (Published 26 February 2014) Cite this as: BMJ 2014;348:g1693

Few papers have had more impact in recent years than the 2009 New England Journal of Medicine article from Atul Gawande’s Safe Surgery Saves Lives Study Group, which showed that surgical checklists could almost halve the rate of deaths and complications in non-cardiac surgery in a wide variety of hospitals (www.nejm.org/doi/full/10.1056/NEJMsa0810119). Although it became an instant classic, the study has been criticised for its simple before and after design and its lack of data on out of hospital complications. A new study looks at the before and after effect of using a checklist in the neurosurgery department of Turku University Hospital, Finland (Scandinavian Journal of Surgery 2013, doi:10.1177/1457496913482255). Unplanned readmissions fell from 25% to 10% after implementation of the checklist (P=0.02) and wound complications decreased from 19% to 8% (P=0.04). Minerva feels that, whatever the limitations of these studies, checklists must be a good thing.

“It’s never lupus” says the diagnostic hero of the television series House. This was a gift to charities supporting people with systemic lupus erythematosus (SLE), who put the slogan on T shirts to raise awareness that SLE is more common than many cancers and can devastate young lives. A study comparing outcomes in 124 patients with adolescent onset SLE and 484 people with adult onset disease (Rheumatology 2014, doi:10.1093/rheumatology/ket488) shows just how true this is. Those who were diagnosed with SLE at 11-18 years of age were more likely to develop lupus nephritis and haemolytic anaemia. Girls with adolescent onset disease had a standardised mortality rate 14.4 times that of an age matched general population.

Feeling a bit cold in his tent, the late Roman emperor Jovian (331-364 AD) called for a brazier of charcoal. He was found dead in the morning. Carbon monoxide poisoning must have been quite common over the millennia during which pans of burning charcoal were used for domestic heating. In the Far East today, charcoal burning has unfortunately become an increasingly popular mode of suicide among young people—first in Hong Kong and Taiwan, and now in Japan (British Journal of Psychology 2014, doi:10.1192/bjp.bp.113.135392). Mass media reporting and social media interaction are thought to have played a role.

In South Korea, a different kind of domestic inhalation poisoning has caused several accidental deaths and cases of serious lung injury. Doctors in Seoul were mystified when a cluster of 17 young patients—six of them pregnant and four in the postpartum period—presented with severe respiratory distress. They were treated with antibiotics, antivirals, and immunosuppressants to no effect: five died and four underwent lung transplantation. It was eventually discovered that they had all been using humidifiers cleaned with a disinfectant that is highly toxic when aerosolised (Thorax 2014. doi:10.1136/thoraxjnl-2013-204135).

Minerva likes ultrasound scanning and enjoys being told the meaning of each blurry grey bit while the sonographer flits from one place to another. The rotator cuff of the shoulder is a complex structure that can easily be imaged by ultrasound, and most of us are happy to believe whatever the reporter says. However, when researchers at Bristol compared ultrasound reports with findings at surgery (Shoulder & Elbow 2014, doi:10.1177/1758573213514498), they discovered that “a positive pre-operative ultrasound scan at our institution predicts an actual rotator cuff tear in 70% of cases. However, it is not accurate with respect to identifying partial-thickness tears or distinguishing them from full-thickness defects.” Caveat lector narrationibus ultrasonicorum, says Minerva.

Anxious people tend to worry that being anxious is bad for them. For example, after elective percutaneous coronary intervention (PCI), they might be anxious that their high levels of anxiety would make them more likely to have a heart attack. Quite the opposite, according to a study of 470 patients from Bremen in Germany (European Journal of Preventive Cardiology 2013, doi:10.1177/2047487313505244): “In patients undergoing elective PCI, higher anxiety levels are positively associated with survival and reduce the risk for major adverse cardiovascular events during the first five years after index PCI.”

Minerva has a very uneasy relationship with guidelines. If they were dependable summaries of reliable evidence to guide dialogue with patients, they would be fine; but they so rarely are. Instead, they often seek to dictate treatment to clinicians irrespective of clinical context or patient choice; they often don’t incorporate numbers needed to treat or to harm; and they often stray into the badlands of expert opinion. Two authors from Scotland examine Scottish Intercollegiate Guideline Network guidelines for incorporation of level D evidence (BMJ Open 2014;4:e004278, doi:10.1136/bmjopen-2013-004278) and find that the longest guidelines have the highest proportion of recommendations based on the lowest level of evidence. So let brevity be the watchword for all guideline writers.

Notes

Cite this as: BMJ 2014;348:g1693

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