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Archive for December, 2008

Dangerous sandwiches identified by The Lancet

19 Dec, 08 | by Dr Dean Jenkins

Some conditions seem to be recurring themes for case reports. To stop the danger of sandwiches being missed perhaps we should change how we teach medical students to take the history of someone who complains of fainting.

Even though swallow syncope is mentioned in many textbooks and has a wealth of case reports and reviews, patients with the condition seem to be difficult to diagnose. Those with no other comorbidities such as hiatus hernia or oesophageal cancer even more so. A case report in The Lancet1 by Dr Christopher Boos and colleagues highlights a particular patient that took some 10 years, two hospital admissions six years apart, and many investigations before the correct diagnosis was made.

Most students, presenting patients with a history of syncope, will mention the relation of the symptom to posture, micturition and cough but who remembers to ask about swallowing? Most descriptions of cardiac syncope stress the importance of a ‘thorough history’ so maybe we should teach a more extensive list. Raising your arms above your head (Pemberton’s sign), turning your head (carotid sinus hypersensitivity), having your hair washed at the hairdresser, any toileting activity, exercising, standing still, standing up, doing almost anything … and swallowing a sandwich.

1) Boos JC, Martin U, Cherry RC, Marshall HJ. Dangerous Sandwiches. Lancet 2008;372(9656):2164.

Doctors revive patient using powerful magnet

12 Dec, 08 | by Dr Dean Jenkins

Transcranial magnetic stimulation is a non-invasive method for stimulating the brain and, in particular, the cerebral cortex. It uses a powerful electromagnet to generate a strong magnetic field that induces electrical current in the brain in much the same as direct stimulation with electricity.

First described in 1985,1 it is being investigated for many conditions including movement and psychiatric disorders.

Researchers from Chicago report a case in New Scientist where it was used to stimulate a road-traffic victim in a persistent vegetative state.2 After several sessions he could speak and obey commands.

This sort of case report makes for fascinating reading since it uses a technology that is unknown to most readers and challenges our beliefs about certain types of therapy. The argument that it is a real effect, and not one that occurred by chance, relies on the fact that the patient was stable for a considerable time before the intervention and responded very quickly. Is this enough proof? Certainly not, but it is good for hypothesis generating.

Mozart referred to Mesmerism in his comic opera Cosi Fan Tutti where the use of magnets was intended to revive the unconscious Albanians (Ferrando and Guglielmo in disguise). Have doctors in Chicago, with a much stronger magnetic field, performed what Mesmer couldn’t?

(1) Barker AT, Jalinous R, Freeston IL. Non-invasive magnetic stimulation of human motor cortex. Lancet. 1985 May 11;1(8437):1106-7.

(2) Geddes L. Man ‘roused from coma’ by a magnetic field. New Scientist 2008;2678:8-9.

Report of successful forequarter amputation

5 Dec, 08 | by Dr Dean Jenkins

Medecins Sans Frontieres (MSF) surgeon David Nott provided a very public case report of successful forequarter amputation this week.

http://www.msf.org.uk/surgery_by_text_message_20081203.news

What made this extraordinary was that he and the patient were in Congo, he had never performed the procedure before and he received instructions on how to do it from a surgical colleague in the UK. The story has highlighted the challenging work that is undertaken by MSF. Mr Nott, a vascular surgeon, gives a month of his time each year helping provide surgical services for MSF.

Would this case report be published in BMJ Case Reports? In its detail it reminds surgeons of the complexities of forequarter amputation, but, that is quite a rare surgical procedure. It highlights how a highly trained individual can undertake a new task with minimal instruction and this encourages breadth of knowledge of anatomy and experience of techniques in surgical training. It also gives an insight into the social network of surgeons who, contrary to popular myth, are not isolated specialists but have strong friendships with colleagues and even send text messages.

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