There is still debate over the extent to which clinical decisions are based on good evidence. An audit of decisions made by three general medical teams in a teaching hospital in Canada found that about two thirds were backed up by evidence from controlled trials (Archives of Internal Medicine 1998;158:1665-8). Only 10 out of 150 decisions were found to be suboptimal when compared with the best available evidence.
Latex allergy sounds trivial but it can be very hazardous for patients having surgery. Surgeons in Florida relate the precautions they took to protect a 13 year old boy during a heart transplant operation (Anesthesia and Analgesia 1998;87:304-5). They used glass syringes, latex free gloves, special nasogastric tubes and urinary catheters, and a latex free blood pressure cuff. All the cardiopulmonary bypass equipment was screened for latex before surgery, and staff took all open boxes of rubber gloves out of the theatre. The boy was given prophylactic drugs but still developed urticaria three times before he went home.
Careful investigation of 43 patients who had had a non-productive cough for an average of 67 months (Thorax 1998;53:738-43) found a cause in 35. On the basis of a successful response to treatment three conditions accounted for almost all these coughs: cough variant asthma, post nasal drip syndrome, and gastro-oesophageal reflux. A few patients, however, remained undiagnosed.
Minerva finds that she is often questioned by young parents about the safety of childhood immunisations. The diseases against which the vaccines give protection have become so uncommon that there is no folk memory of their dangers and the misery they cause children. In countries such as Australia, with a vigorous anti-immunisation lobby, parents’ doubts are exacerbated, and a review in the Australian and New Zealand Journal of Public Health (1998;22:17-26) warns that the opposition is becoming more organised. Only 52% of infants aged 3 months to 5 years were fully immunised in 1995, and in the first 10 months of 1997, 6468 cases of pertussis and 535 of measles were notified throughout Australia.
Another potent cause of loss of public confidence in medicine is the readiness of employing authorities to suspend pathologists when some of their histological or cytological diagnoses come under question. An article in the Journal of Clinical Pathology (1998;51:649-51) calls for wider recognition of interobserver variation and acceptance that all laboratories make mistakes. An unpleasant feature of the investigation of pathologists who have been suspended is that “women doctors are much less likely to get their jobs back than men whilst, at the same time, they are more often found not guilty of any professional misdoing.”
The cystic fibrosis gene was identified in 1989, and since then over 750 mutations have been found, though one of these accounts for 70% of the total of typical cases. Two papers in the New England Journal of Medicine (1998;339:645-58) report that other abnormalities in the gene may sometimes lead to chronic pancreatitis in people with no evidence of chest disease and non-diagnostic sweat tests. One or two mutations in the cystic fibrosis gene may also be responsible for a high proportion of otherwise unexplained sterility in men.
Anorexia nervosa is widely perceived as carrying a high risk of suicide: by some estimates half the deaths from the disease are suicides. Yet an analysis of death records of 5 million women in the United States (American Journal of Public Health 1998;88:1206-7) found anorexia nervosa listed as a cause of death in 571 cases of whom only 8 were categorised as suicides. Seventy suicides were listed in a control group of 1713 women matched for age and race.
Britain may be short of doctors, but New York City has a glut of gastroenterologists. A survey of 59 who had recently completed their training found that 15 were unemployed and 10 had too little work (American Journal of Gastroenterology 1998;93:1211-6). The conclusion of the report is that “physicians would rather be unemployed in a geographic location of their choice than migrate to another part of the United States.”
Minerva likes studies which follow up patients for a long time, so she read with interest a report from Finland of 1172 women with breast cancer treated 15-30 years previously (British Journal of Cancer 1998;78:795-9). Of these 339 had unilateral node positive lesions treated by radical mastectomy and local radiotherapy but no systemic drugs or hormones. Follow up showed that 26% had survived for 15 years, indicating that spread to the axillary nodes does not always mean metastatic disease.
The Everest marathon reaches a height of 5500m (18,450 ft) so it is not too surprising that the winner’s time in 1997 was 4 hours 15 minutes and 29 seconds (British Journal of Sports Medicine 1998;32:262-5). There were 88 potential runners backed up by a support team of 30 people, including 10 doctors, who were themselves supported by 50 Sherpas and porters. The main medical problem was blistered feet—too many people had come wearing new boots.
