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Archive for July, 2009

Side effects of evidence-based medicine

22 Jul, 09 | by Emilia Demetriou

This case highlights the challenge of implementing evidence-based medicine and guidelines. Each patient is an individual and may not fit within the group that has helped define the evidence for a particular clinical procedure. In this article the authors discuss two cases of pre-operative patients that did not fit the ‘healthy’ group they were thought to be in.

Side effects of evidence-based medicine

The wonders of brain plasticity

22 Jul, 09 | by Dr Dean Jenkins

A German girl born with a missing right hemisphere of her brain has baffled her doctors by having normal vision.

http://news.bbc.co.uk/1/hi/health/8159631.stm

“[MRI] Scans on the girl showed that the retinal nerve fibres carrying visual information from the back of the eye which should have gone to the right hemisphere of the brain diverted to the left.

Dr Lars Muckli, of the university’s Centre for Cognitive Neuroimaging, working with German colleagues from Frankfurt, said: ‘The brain has amazing plasticity but we were quite astonished to see just how well the single hemisphere of the brain in this girl has adapted to compensate for the missing half‘.”

This remodelling would have occured very early in-utero.

Orthopaedic surgeons move young woman’s heart

22 Jul, 09 | by Dr Dean Jenkins

The BBC are carrying an interesting case report of a young woman with severe scoliosis. The deformity had shifted her mediastinum and heart to the right but, after corrective surgery, her symptoms of back pain and the heart shift have resolved.

http://news.bbc.co.uk/1/hi/health/8160522.stm

“A spokeswoman for the Scoliosis Association said: ‘If scoliosis goes untreated, it will cause massive effects on heart function and reduce breathing capacity because the lungs are getting smaller.‘ ”

The case report includes some before and after CXRs and the patient perspective.

Gastric outlet obstruction from a caecal volvulus, herniated through epiploic foramen: a case report

15 Jul, 09 | by Emilia Demetriou

This is an unusual, and we think first reported, case of gastric outlet obstruction due to herniation of the caecum and ileum through the epiploic foramen. It demonstrates the usefulness of contrast CT in the pre-operative evaluation of such patients presenting with acute abdomen. What I particularly like is the hand drawn operative findings by the surgeon. In these days of multi-media and graphics designers it is good to be reminded that the best way to demonstrate something may be to simply draw it with a pencil!

Gastric outlet obstruction from a caecal volvulus, herniated through epiploic foramen: a case report

Lancet reports girl feeling well and living after her heart is removed.

14 Jul, 09 | by Dr Dean Jenkins

“Follow-up of Hannah Clark—who had a donor heart grafted onto her own after suffering heart failure as an infant—after having the transplanted heart removed, now aged 16.” is reported in The Lancet

Lancet Online First 14th July 2009

This case report not only explores the surgical management of heart failure but also the immunology and consequences of heart transplantation.

Wii knee revisited: meniscal injury from 10-pin bowling

6 Jul, 09 | by Emilia Demetriou

New sports bring new injuries but this case report describes trauma from what initially appears to be a child’s indoor computer game.

Wii knee revisited: meniscal injury from 10-pin bowling

The earliest 1918 pandemic “influenza” case report?

3 Jul, 09 | by Dr Dean Jenkins

King Alfonso of Spain appears to be the first case reported in the newspapers in May 1918 followed by several cases in the medical press including a case series of fifty in July 1918 in the BMJ.

I’ve been looking for the earliest case reports of the flu in 1918 which seems to have first been reported in San Sebastian, Spain in February 1918 – hence the name Spanish flu. However, it probably originated somewhere else.

There are cases reported in Fort Funston, Kansas in March and on the Western Front in French and British soldiers in April1. A Sergeant John Acker said that the troops called it “three day fever”2.

There is much debate in the medical journals at this time of “trench fever” and “weak heart” and a good number of obituaries with influenza as a cause of death.

In June the BMJ is prompted to respond to the newspaper reports of King Alfonso’s illness – a third of Madrid are ill by this time. In the article it says, “We cannot help feeling that in the absence of any bacteriological proof, the extreme low mortality or its practical absence, and the possibility that the disease is gastro-intestinal influenza, render alarmist suggestions premature, and they do not seem to be countenanced by the medical profession in Spain” and went on to say that influenza was the probable cause. 3

The following week the BMJ updated the story saying, “The widespread epidemic of an acute catarrhal affection in Spain, which was stated in our last issue to be most probably influenza and attended by little or no mortality, is now reported to have caused 700 deaths in ten days, but if the number of cases has been as large as reported the case mortality must have been very low.”4

The first published cases in the BMJ come in the form of a case series of the first fifty cases at the Central Royal Air Force Hospital, Hampstead from July 1918. It contains useful advice on the presentation, comparison with physical signs from the 1889 pandemic, fever charts, differential diagnosis and the practical management of cases.5

What I find interesting is how the reporting seems to have mirrored the current pandemic. At the beginning there is doubt over the diagnosis, the debate on case fatality rates and whether it would be as severe as the previous pandemic, and later it focusses on the clinical management of cases and health policies. I hope the 2009 pandemic will not continue to mirror the 1918 one and become more deadly in late 2009 through 2010.

Remember to keep up to date with the current swine flu at the pandemic flu blog.

1) Tucker S (Editor). “Influenza Pandemic (1918 – 1920)” in “World War I a student encyclopedia”. ABC-CLIO, 2006.

2) Kolata G. Flu: the story of the great influenza pandemic of 1918 and the search for the virus that caused it. Touchstone, 2001.

3) No author listed. The reported epidemic in Spain. Br Med J 1918;1:627.

4) No author listed. The reported epidemic in Spain. Br Med J 1918;1:653.

5) Gotch OH, Whittingham HE. A report on the “influenza” epidemic of 1918. Br Med J 1918;2:82-85.

What is the most highly cited case report?

1 Jul, 09 | by Dr Dean Jenkins

One criticism against case reports is that although they are widely read they are not often cited. I’ve therefore been looking for the case report or case series that has the highest number of academic citations.

At the moment the best I’ve found is:

James A.R. Nicoll, David Wilkinson, Clive Holmes, Phil Steart, Hannah Markham & Roy O. Weller. Neuropathology of human Alzheimer disease after immunization with amyloid-beta peptide: a case report. Nature Medicine  9, 448 – 452 (2003)

with 641 citations listed by Google Scholar.

ISI’s Web of Knowledge has the ability of ranking searches by “Times Cited” but I haven’t been able to find one with more citations. PubMed and Highwire don’t seem to have a “sort by number of citations” feature.

I’m sure that some classic cases such as Sydenham’s account of gout or Hippocrates’ description of diabetes have been cited in many hundreds of textbooks alone but how should one judge the world record holder? Should it be the absolute number of citations – in which case Hippocrates has over 2000 years advantage – or the peak number of citations per year?

Arguments about the compatibility of different counts of citation numbers aside … any suggestions for other highly cited case reports would be most welcome.

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