Minerva: July 2003
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.
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,
its striking that hes no older than the average hospital registrar.
The
facial and dental consequences of prolonged finger sucking
are well known, but deformity of the sucked finger is much less common.
A 15 year old girl had sucked her right index finger every night since
birth. This had resulted in a 90° anticlockwise
rotational deformity. As an infant she had been nursed on her front and
this may have been why her finger, rather than her thumb, had been
sucked. The deformity was corrected with an osteotomy and K
wiring.
Mark Howard Wilson clinical fellow
Helena Van Dam, clinical fellow
Charles Nduka, specialist registrar
Mohammed Shibu, consultant, department
of plastic surgery, Royal London Hospital, London E1
1BB
Submissions for
this page should include signed consent to publication from the
patient
Chlamydial infection in
men may not be as devastating as it can be in women, but as its
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
Crohns disease often need multiple surgical
procedures, so its 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 its a drop in
the ocean of the one billion targeted worldwide (Weekly
Epidemiological Record
2003;78:171-9).
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
Submissions
for this page should include signed consent to publication from the
patient
A
man without qualifications worked for 18 months as a senior
clinical scientist before being found guilty of defrauding the NHS of
£59 000. He used a bogus PhD in philosophy to obtain the
job. Hes been sentenced to 120 hours of community
service and was ordered to pay court costs. Minerva is
curious about what he actually did at work because his actions
apparently did not affect any patients at the trust that employed
him.
studentBMJ 2003;11:219-262 July ISSN 0966-6494
