Surgical Recall |
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Shadow in Tiger Country |
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The World I Made for Her |
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Churchill's Pocketbook of Differential Diagnosis |
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The Human Face |
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Mature but poor |
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Le langage |
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Minerva |
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Minerva Last December, UK's Nottingham University accepted £3.8m from British American Tobacco to fund an International Centre for Corporate Social Responsibility. Readers who are lost for words at the mendacity of this donation will find them all in a leader in Tobacco Control (2001;10:1.2). It starts by comparing the money with profits from pornography, arms dealing, national plunder, and genocide. Then it argues that at least pornographers and genocidal murders don't torture universities with offers of cash, unlike the tobacco industry "which has hung about university research funding corridors like a wheel of ripe cheese in a sunbaked phone booth." We are entering a new phase of scientific uncertainty where meta-analyses, as well as single studies, can contradict each other. General practitioners wanting to know whether or not to eradicate Helicobacter pylori in patients with non.ulcer dyspepsia have two meta.analyses to go on. One (BMJ 1999;319:1040.4) found that it helps, another more recent meta.analysis (Annals of Internal Medicine 2001;134:361.9) insists that it doesn't. Both have their limitations, partly because the term non.ulcer dyspepsia is variably defined. Bigger, better trials will hopefully follow. There have been many false dawns in the search for an effective treatment for severe sepsis, but the latest treatment, activated protein C, looks more hopeful than most (New England Journal of Medicine 2001;344: 759.62). It is antithrombotic, antiinflammatory, and reduces mortality from sepsis by nearly a fifth, according to a large randomised trial. One expert commentator was so impressed, he says, that all patients with sepsis and end organ failure should be given the drug forthwith. The UK govern. ment will probably want to see cost effectiveness data first. "Awareness" is every anaesthetist's bogey. man, and the source of preoperative anxiety for many patients. Unfortunately, detecting the presence or absence of consciousness in paralysed people is much more difficult than it sounds. Hope currently rests on a sophisticated electroencephalograph which computes a single number, the bispectral index, from a complex analysis of the variables (Medical Journal of Australia 2001;174:212. 3). The manufacturers certainly believe in this monitor, and their series of more than 1.2 million patients looks promising, but anaesthetists and patients will need more than this to convince them. Misoprostol is beginning to look like a reasonable alternative to traditional methods for inducing labour in pregnant women at or beyond term. Unlike other agents it can be given by mouth, though a recent clinical trial suggests it is more effective if the tablet is placed in the vagina (British Journal of Obstetrics and Gynaecology 2001;108:23.6). Women in the vaginal group needed fewer doses, delivered eight hours sooner, and had less oxytocin than women who swallowed the 50 ìg tablets. This trial hints at worse fetal outcomes with the vaginal route, a find. ing that needs further investigation. US doctors who want a clear conscience and a truly independent practice can now pledge to be free of all drug company promotion by joining "no free lunch" (www.nofreelunch.org), a US campaign opposed to drug company inducements of all kinds. For $25, members receive a badge, a T shirt, and the resources to enlighten their colleagues and institutions about the malign influence of supposedly harmless gifts. One Canadian doctor writes that he was so wracked with guilt after a lavish night out that he took two years to get over it (Canadian Medical Association Journal 2001;164:464). An audit in one of London's tertiary paediatric intensive care units shows that medical and nursing staff rarely continue to treat children with a hopeless prognosis (Archives of Disease in Childhood 2001;84: 265.8). Staff managed 34 children in this category out of 662 audited. Those with a very poor outlook consumed less than 1% of total bed days. Managers looking for more efficiency will probably be disappointed if they target high cost paediatric intensive care units, say the authors. The cost of futile treatments is already low. In most Western populations, men are considerably more likely than women to commit suicide. In NHS doctors, however, the risk is higher for women (Journal of Epi. demiology and Community Health 2001;55:0. 4). A study of 223 suicides in doctors over a 16 year period confirms that anaesthetists, psychiatrists, community health doctors, and general practitioners are all more prone to suicide than general physicians. The researchers hope that as more and more women enter senior posts in medicine, their lot will improve and their risk of suicide will decrease. About 8% of European men are colour blind. Most of them have trouble distinguishing red from green, so colour blind men can have trouble recognising blood in their bodily fluids, write doctors from New York (Archives of Internal Medicine 2001;161: 461.5). Ten colour blind volunteers were less likely than controls to spot blood in photographs of sputum, urine, or particularly stool. In theory, this could delay the diagnosis of a dangerous cancer. Perhaps questions about colour blindness should be part of routine clerking. It's hard to be warm, caring, and friendly all the time, but there's evidence that people respond well to a doctor with a good bedside manner, including a meta.analysis in a recent issue of the Lancet (2001;357: 757.62). It concludes that outcomes in chronic diseases such as hypertension are generally better when the doctor is positive and reassuring, although the effects are small. These aspects of medicine are long overdue for some decent research: the emotional element of care has been ignored since Hippocrates first suggested it might be important, in 400 BC.
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