Eleven Kashmiri children underwent ligation of a patent ductus arteriosis under general anaesthetic in a hospital in Ladakh, India (3500 metres above sea level). Cardiac surgery had not been attempted at this hospital before, but all children tolerated the stress of thoracotomy and the closure of a left to right shunt well—they were already acclimatised to the high altitudes of the Himalayas and were therefore adapted to hypoxaemic conditions (National Medical Journal of India 2005;18: 137-8).
Is Munchausen's syndrome by proxy an example of medical misogyny? A writer in Medical Hypotheses ( 2005;65: 440-7) thinks so. She says that late stage Lyme disease is so little understood or recognised by doctors, that there's a tendency to accuse mothers of fabricating their children's symptoms and labelling it Munchausen's syndrome by proxy. “Modern medicine's tendency to trivialise women's `offbeat' concerns” and “spirochaetally naïve” doctors who are not aware that advanced borreliosis seronegativity is often the rule frequently “results in the misogyny of mother-devaluation.”
Long distance cyclists are prone to “cyclist palsy” due to prolonged gripping of the handlebars. Nerve conduction studies performed on 28 adults after a 420 mile cycle event confirmed that motor latencies of the deep branch of the ulnar nerve were commonly prolonged, to the first dorsal interosseous. Three hands showed electrophysiological and symptomatic worsening of carpal tunnel syndrome. Nerves to the little finger were not significantly affected (American Journal of Sports Medicine 2005;33: 1224-30).
A significant link between the proportion of nicotine absorbed from environmental tobacco smoke during childhood, and teenage smoking, is reported in CMAJ ( 2005;173: 377-9). Follow up data from 13 year olds in Montreal found that a high salivary cotinine level when younger is an independent predictor of becoming a teenage smoker. The efficient absorption of nicotine seen in some of these children may be related to physiological factors such as lung capacity.
A comparison of internal fixation with total hip replacement for displaced femoral neck fractures in 102 elderly but generally healthy patients reports that those who had received hip replacements had done better after four years. This contradicts conventional wisdom that fixation is better than arthroplasty. In this study, complication and re-operation rates were significantly lower after joint replacement surgery, and hip function and quality of life issues were just as good (Journal of Bone and Joint Surgery (Am) 2005;87: 1680-8).
Non-specific abdominal pain accounts for up to 40% of all adult surgical admissions. These are patients with abdominal pain for which no immediate cause can be found, and for whom surgical intervention is not required. A case-control study comparing 300 patients presenting with acute abdominal pain and 300 healthy volunteers without pain found that 3% of patients proved to be histologically positive for coeliac disease, rising to 10.5% in those with non-specific abdominal pain, all of whom had other symptoms or diseases associated with coeliac disease (Annals of Surgery 2005;242: 201-7).
The optimal time to undergo carotid endarterectomy after a stroke is within two weeks of the first event. A study of delays in one UK centre found that just 6% of suitable patients had surgery within two weeks and 43% within 12 weeks. The risk of recurrent stroke in those with more than 50% carotid blockage before surgery was estimated to be 21% at two weeks and 32% at 12 weeks. The delays are similar to those reported in several other countries, and are associated with very high risks of what otherwise are preventable events (Neurology 2005;65: 371-5).
Figure 1.
A 63 year old man presented to the emergency department in the early hours with an obvious deformity of his right fifth proximal interphalangeal joint. X rays were taken immediately after he was triaged, and he then returned to the waiting room. As the department was very busy, the sister in charge requested that the orthopaedic team see the patient. He was found reclining on the hard seats of the waiting room with his right hand behind his head. The deformity seemed to have resolved. The finger was buddy strapped, and x rays confirmed the reduction by mild inebriation, a three hour wait, and hard seating.
Michael R Whitehouse (mike_whitehouse@yahoo.com), senior house officer department of orthopaedics, Western General Hospital, Weston-super-Mare BS23 4TQ
The consequences of high blood pressure are not just possible stroke, but a shorter life expectancy generally. Data from the Framingham heart study shows that, compared with normotensive people, 50 year old men and women with hypertension have shorter lives; they get cardiovascular and cerebrovascular disease earlier, and have these diseases for longer. Normotensive men lived 5.1 years longer and women 4.9 years longer than people with high blood pressure (Hypertension 2005;46: 280-8615983235).
Presenting the results of research to participants is supposed to be good practice, and when haematologists who were presenting their work at the American Society of Hematology's annual meeting were surveyed about their practice, 69% said they supported the idea of doing so. Yet only 30% of the 197 who responded said they had a formal plan for returning research findings, of whom 19 said they would return a summary plus an individual's results. Just 7% said their own institutional review body insisted on returning research data to participants (Blood 2005;106: 1199-202).
People who develop anorexia nervosa struggle to maintain or gain weight, but according to a study in the American Journal of Clinical Nutrition ( 2005;82: 296-301), their disturbed eating behaviours often persist when they regain body weight and their eating disorder and psychological symptoms improve. Both before and after weight restoration, average food consumption and meal size remained lower among women with anorexia than among healthy controls.
Minerva was interested by the notion that brief psychotherapy might benefit patients in the early stages of Alzheimer's disease. A small pilot study comparing six sessions of psychotherapy with usual care found no improvement on most of the outcome measures, although therapy seemed to improve the carers' reactions to some of the symptoms. Minerva wonders if this could be called therapy by proxy (British Journal of Psychiatry 2005;187: 143-7).