Minerva: September 2000
Smoking is expensive for smokers and for their employers. Perhaps that's why over 90% of employers in Scotland operate some sort of smoking restriction policy (Tobacco Control 2000;9:187-92). Only a third, however, insist on smoke-free buildings. The tobacco experts who surveyed Scottish workplaces estimate that smoking still causes £450m worth of lost productivity each year in Scotland alone. One solution is for employers to help employees quit.
Could you attach the correct eponym to pictures of Chauffeur's, Smith's, Galeazzi's, Monteggia's, Colles', and Barton's fractures? Neither could 88% of orthopaedic and emergency medicine trainees in three UK hospitals (Injury 2000;31:425-6). Unsurprisingly, four fifths of the trainees surveyed said they thought that eponyms should be abandoned as a way of describing fractures.
There is already some evidence that thin women have a higher than average risk of hip fracture in later life. Results from a US cohort study show that they also have a higher risk of rib and pelvic fractures (Annals of Internal Medicine 2000;133:123-7). Lower bone mineral density at the hip accounted for most of the association between body weight and fractures in this study, although the authors can't explain why the association didn't extend to fractures of the humerus, elbow, wrist, ankle, or foot.
Jargon is a big problem in medical informatics and must surely contribute to doctors' dislike of technology. Try translating "Towards vocabulary domain specifications for health level 7-coded data elements" after a heavy lunch. The title of the second paper in this month's Journal of the American Medical Informatics Association (2000;7:343-56) is no better: "WebEAV: automatic metadata-driven generation of web interfaces to entity-attribute-value databases." No, really.
In July the BMJ joined in the general media coverage of a new "first" in cardiac surgery-coronary artery bypass in an awake patient (2000;321:135). Anaesthetists and surgeons at Guven Hospital in Turkey must have been confused by the interest, as they have been doing it this way for over two years (Annals of Thoracic Surgery 2000;70:91-6). Their first five patients all did well, although when they reported their series in July one commentator, an American, said it would never catch on. Ironically, all last week's fuss was over the first US patient.
Everyone hates being overloaded and unable to do their job properly, but a high workload for staff in intensive care units can mean higher death rates for patients (Lancet 2000;356:185-9). A retrospective look at data from one hospital in Scotland showed that patients' risk of death was doubled at times of high stress. These ominous findings deserve prospective evaluation, say the researchers, who advocate a cluster randomised trial in busy intensive care units allocated different staffing ratios.
Revue Prescrire, a French pharmacology journal, reminds readers about the cutaneous side effects of topical non-steroidal anti-inflammatory drugs, many of which are available over the counter (2000;9:114). Skin eruptions resembling eczema are reported regularly, it says. These can be severe, prolonged, and extend beyond the area of skin where the drug was applied. About a third of reactions are photosensitive, so doctors can expect more in the summer months. Patients should be warned not to overuse these drugs and to stay out of the sun when they do, particularly when using ketoprofen.
Reports of mercury poisoning from beauty creams containing calomel, or mercurous chloride, also surface regularly. The latest, in the Western Journal of Medicine (2000;173:15-8), describes a young boy who presented with a severe demyelinating polyneuropathy after using the Mexican "Crema de Beleza-Manning" on his acne for five months. Later surveys found this cream in bathroom cabinets all along Mexico's border with the United States. Most users had high urinary concentrations of mercury.
The medical school in South Carolina tries hard to pick the "right" applicants, putting them through a complex admissions procedure including tests of academic performance and three one-to-one interviews. Students' ranking during selection did not, however, predict their performance at a later OSCE (objective structured clinical examination) in family medicine or the satisfaction of the patients they had to examine (Academic Medicine 2000;75:743-7). It's very difficult to predict students' future performance, the disappointed investigators conclude.
Vegetarians and others who would rather not eat bulls' testicles should look carefully at the ingredients list of any "herbal" dietary supplements before buying, a doctor writes to the New England Journal of Medicine (2000;343:304-5). Anything listing "Orchis" should be left on the shelf. One product, which he doesn't name, contains 17 types of bovine offal, including pituitary, pineal gland, placenta, prostate, and thyroid.
Two papers in JAMA consider the growing problem of cybersex. Both find a clear link between looking for sexual partners via the internet and various sexually transmitted diseases, including syphilis (2000;284:443-6, 447-9). Fortunately, the internet is as good at spreading information as it is at spreading diseases. If a chat room turns out to be the source of an outbreak, users can be warned immediately of the risk.(See Figure 1)
Doctors at the Mayo Clinic write that morbid obesity is a national crisis for the United States. The solution for some patients is drastic surgery, and the favoured approach at the Mayo Clinic is the Roux-en-Y gastric bypass (Mayo Clinic Proceedings 2000;75:673-80). Nearly 200 patients had the procedure between 1987 and 1998 and lost an average of 52 kg in the first year. Many of them were lost to follow up, but three quarters of those that weren't were still "cured" three years after surgery. These results echo those of other surgical series. There are no randomised trials.
A 21 year old medical student from Sheffield was hit on the left side of the face by an opponent's knee during a game of rugby. He went to a local accident and emergency department, where doctors sutured a 15 mm laceration across the left eyebrow. The next morning he rose from bed and blew his nose. Immediately he felt something "go" in his left cheek and developed marked left sided periorbital and facial oedema with surgical emphysema. He was referred to a maxillofacial unit, where a hair line fracture of the maxilla communicating with the left maxillary sinus was diagnosed. He was treated conservatively with antibiotics and made a full recovery. Forceful nose blowing should be avoided after facial injuries.
Steven J Gill, medical student, Sheffield University S10 2TN;
Geoffrey Gill, consultant physician, Walton Hospital, Liverpool L9 7AL
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studentBMJ 2000;08:303-346 September ISSN 0966-6494
