Aneurysm interventions . . . and other storiesBMJ 2019; 364 doi: https://doi.org/10.1136/bmj.l581 (Published 14 February 2019) Cite this as: BMJ 2019;364:l581
Unruptured intracranial aneurysms
The increasing use of brain imaging means that increasing numbers of unruptured intracranial aneurysms are being identified. Many are likely to remain asymptomatic but some will rupture—with potentially devastating effects. A systematic review tries to assess the risks of preventive intervention, which are far from negligible (JAMA Neurol doi:10.1001/jamaneurol.2018.4165). For endovascular procedures, the pooled risk for any complication was around 5% with a case fatality of 0.3%. For neurosurgical interventions, the risk of complications was around 8% with a case fatality of 0.1%. The highest risks were for aneurysms in the posterior cerebral circulation.
Writer’s cramp and musician’s cramp are dystonias of the hand and forearm that are specific to particular tasks. Despite involving the same muscles, performance of other motor tasks is often unimpaired. These dystonias are disabling and hard to treat. A report of a large series of cases from a Japanese neurosurgical unit claims that unilateral stereotaxically placed lesions in the ventro-oral nucleus of the thalamus are a safe and effective intervention (Neurology doi:10.1212/WNL.0000000000006818). The procedure is carried out under local anaesthetic and there’s a remarkable photograph of a patient holding a violin while surgery is in progress.
Twenty years ago, the Harvard Medical Practice Study drew attention to the number of patients who suffered harm as a direct result of medical errors (N Engl J Med doi:10.1056/NEJM199102073240604). Its findings provoked a wave of initiatives to improve patient safety. An analysis of death certificates from the US suggests that they have been moderately successful. Age standardised mortality from the adverse effects of medical treatment has fallen by around 20% since 1990 (JAMA Netw Open doi:10.1001/jamanetworkopen.2018.7041). Older people are at the highest risk. Mortality from adverse medical events was 20 times higher in people aged 70 and older than in people below 50.
Dapsone for chronic urticaria
How do you help patients with chronic idiopathic urticaria when treatment with high doses of H1-antihistamines fails? Dapsone might be the answer, according to a review of a series of 79 patients treated at a tertiary care centre in New York. More than three quarters of those treated with dapsone experienced some improvement and around a third became symptom free (JAMA Dermatol doi:10.1001/jamadermatol.2018.3715).
Flashing lights and sirens
Emergency response ambulances frequently use flashing lights and sirens to warn other drivers and demand right of way. Several studies have shown that this doesn’t save much time. Except in rare circumstances such as airway obstruction or uncontrolled haemorrhage, any benefits for patients are probably small. A nationwide survey from the US finds that ambulances operating with lights and sirens are more likely to be involved in crashes, especially during transport of patients to hospital. It calls for research to quantify the trade off between the risks of the journey and the potential benefits of faster transport. (Ann Emerg Med doi:10.1016/j.annemergmed.2018.09.032).