Einladung zum 1. Langener Intensivsymposium

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Interactive Medical Cases

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Ethical Challenges in Short-Term Global Health Training

This series of cases introduces trainees and others involved in global health research and service to ethical issues that may arise during short-term training experiences abroad. Being able to recognize and navigate these issues is critical for avoiding harm to communities as well as facilitating a long-term, productive collaboration for the betterment of global health (1). The Working Group on Ethics Guidelines for Global Health Training (WEIGHT) has recently published best practice guidelines for this setting (2).

Using ten cases adapted from real-world experiences, this series builds on the WEIGHT guidelines and helps users identify and develop strategies for navigating some of these ethical issues. Although based on true scenarios, many details, including names and locales, have been changed to protect individual and institutional privacy and to assist in meeting educational objectives.

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Case challenge

A 29-year-old man was seen in an outpatient clinic because of abdominal pain, fever, and weight loss. He had had a respiratory illness approximately 2 years before this evaluation. Chest imaging revealed tiny nodules in both lungs. What is the diagnosis? Mehr

Simple and Complex

A 44-year-old man presented to the emergency department with chest pain that had started 1 hour earlier and had awakened him from sleep. The pain was severe, substernal, burning, radiating to the left arm, and accompanied by nausea and nonbilious, nonbloody vomiting. For the past month he had experienced intermittent chest pain of a similar character but less intense. The pain was not related to exertion and lasted for hours to days at a time. Antacids and omeprazole had provided temporary relief. He reported no dyspnea, lower-extremity edema, immobility, fever, cough, or trauma. Mehr

At a Loss

A 31-year-old woman who had been unable to eat or drink for the preceding week was admitted to the hospital. For the preceding 8 months she had had nausea, vomiting, and abdominal discomfort and several episodes of crampy epigastric pain with vomiting and intermittent chills and sweats, but no documented fevers. She also had loose, pale stools occasionally, but these episodes did not represent a notable change
from her baseline. Gradually increasing fatigue, loss of appetite, and a recent weight loss of several kilograms were also reported. The patient’s medical history included hypertension, obesity, and migraine headaches. She had undergone Roux-en-Y gastric bypass 5 years before presentation and subsequently lost approximately 45 kg (100 lb). Her weight had been stable for the past few years; her body-mass index (BMI, the weight in kilograms divided by the square of the height in meters) was 33. She had undergone laparoscopic cholecystectomy 10 years before presentation. Her only medication was nifedipine, and she
took a multivitamin on occasion. Mehr

Older Still...

In April, 2011, a 52-year-old man presented to us with a 7-day history of fleeting joint pain and stiff ness of his hips, right elbow, left shoulder, and lumbar region. The symptoms were worst in the evening and accompanied by myalgia in his quadriceps and gastrocnemius muscles. He had been unwell for 3 weeks with a swinging fever (>39°C), sore throat, cervical lymphadenopathy, and an intermittent pink rash across his chest, arms, and thighs. He had had no previous similar episodes and no recent diarrhoea, genitourinary symptoms, or red eyes. He denied any new sexual partners or travel to the tropics. On examination, he was febrile (temperature 39·2°C). He had swelling and reduced movement of his right elbow and left shoulder and discomfort on mobilisation of his lumbar spine. A striking pink rash covered his chest, arms, and thighs. There was no palpable lymphadenopathy or abdominal mass. Mehr

Woran wir sterben

Unter dem Titel "Global Burden of Disease" wurden erstmals 1992 alle Menschen erfasst, die innerhalb des Jahres gestorben waren. Außerdem beschrieb die Studie die wichtigsten Risikofaktoren für die Gesundheit. Im Dezember 2012 wurde nun, zwanzig Jahre später, eine Folgestudie veröffentlicht, basierend auf den knapp 53 Millionen Todesfällen des Jahres 2010. Das Fazit: Die Bevölkerung ist in der Zwischenzeit deutlich gesünder geworden. Infektionskrankheiten wurden zurückgedrängt, dafür sterben mehr Menschen an Altersgebrechen und Zivilisationsleiden. Mehr

Zwerchfelldefekt

A 76-year-old man was referred to our hospital because of hemoptysis. He had had pulmonary tuberculosis six years before his current admission, and he had had an abnormal chest radiograph during adolescence. A chest radiograph showed an opacity in the right hemithorax that was accompanied by numerous masses, each surrounded by an air crescent (Panel A). Bowel sounds were heard over the right chest, and a barium enema showed that the colon filled the right hemithorax (Panel B). Computed tomography suggested hypoplasia of the right lung and herniation of the bowel through the posterior diaphragm (Panel C). Bronchoscopic examination showed no bleeding in any of the bronchial lumina or orifices. Examination of the sputum yielded no specific pathogens or malignant cells, and the hemoptysis ceased spontaneously. Follow-up on an outpatient basis without specific therapy was planned. Since the patient's history did not include a traumatic accident, the radiographic findings were compatible with a diagnosis of congenital diaphragmatic hernia.

Porzellangallenblase

A 45-year-old woman was hospitalized with a seven-day history of fever and pain in the right upper abdomen. Ultrasonography (Panel A) showed gallstones (large arrows), including one in the cystic duct, leading to an enlargement of the gallbladder (diameter about 5 cm) and calcification of the wall (small arrows). Computed tomography (Panel B) confirmed the presence of calcification of the gallbladder wall, or porcelain gallbladder (small arrow), and gallstones (large arrow). The patient declined cholecystectomy, which is the usual treatment, and was treated with antibiotics. Two weeks later, the fever and pain had resolved. A large, solitary calcification in the right upper abdomen may indicate disease of the gallbladder, adrenal glands, kidneys, lungs, or chest wall. With respect to the diagnosis of porcelain gallbladder, ultrasonography is as sensitive as abdominal radiography and computed tomography. Patients with a calcified gallbladder have an increased risk of gallbladder cancer.

Pankreatitis

A 78-year-old man had fever, intermittent nausea and vomiting, and increasing abdominal pain for one week. He said he did not use alcohol. On examination, he had a distended abdomen and marked epigastric tenderness. His serum amylase and lipase levels were 1485 and 1608 U per liter, respectively. A contrast-enhanced computed tomographic (CT) scan of the abdomen showed a large amount of gas that severely distorted the pancreatic parenchyma (arrow) and a distended gallbladder with a 2-cm stone in its neck (arrowhead). The patient was treated with bowel rest, fluids, and imipenem. A CT scan one week later showed increasing emphysematous changes in the pancreas, with fluid replacing the pancreatic parenchyma. A percutaneous catheter was inserted, and Escherichia coli was isolated. The patient subsequently underwent pancreatic necrosectomy and cholecystectomy and was discharged three weeks after surgery. Emphysematous pancreatitis is a severe complication of acute pancreatitis. It is diagnosed on clinical grounds and on the basis of the radiologic finding of gas in the retroperitoneum. Retroperitoneal gas in a patient who has clinical evidence of pancreatitis warrants early use of antibiotics, percutaneous drainage of the fluid collection, and (if there is no clinical response to those measures) surgical resection of the infected necrotic tissue.

Morbus Crohn

A 63-year-old woman with a history of Crohn's disease presented with abdominal pain and diarrhea, findings consistent with a flare of her disease. One week after treatment with infliximab, she returned with worsening abdominal symptoms. An abdominal radiograph (Panel A) showed colonic dilatation and intraluminal polypoid filling defects that suggested the presence of innumerable inflammatory pseudopolyps. (In contrast, "thumbprinting" due to submucosal edema has a more uniform haustral distribution.) Colonography by means of volume-rendered computed tomography with an intraluminal perspective (virtual colonoscopy) (Panel B) generated the endoscopic appearance of inflammatory pseudopolyposis. Polyposis syndromes, such as familial adenomatous polyposis, could give rise to a similar appearance on imaging, although the clinical presentation would differ from that of inflammatory pseudopolyposis. A subtotal colectomy was performed, and on gross examination, areas of denuded mucosa surrounding multifocal islands of edematous mucosa were noted.

Milz Sarkoidose

A 45-year-old woman with a history of mediastinal sarcoidosis, who had been treated with oral corticosteroids six years previously, presented with pain in the left upper quadrant of her abdomen. Computed tomography (CT) revealed heterogeneous splenomegaly with multiple hypovascular nodules (Panel A). After two years of follow-up, the patient still reported abdominal pain, and the spleen had increased in size, from 16 to 20 cm. A laparoscopic splenectomy was performed; a specimen is shown in Panel B. Pathological examination confirmed the presence of sarcoidosis in the spleen and the lymph nodes of the splenic hilum. The patient did well with no further treatment and had no sign of recurrence on thoracoabdominal CT at two years of follow-up.

Kolonkarzinom

A 74-year-old man was referred for evaluation after a positive fecal occult-blood test. He had no history of cancer and no family history of colorectal cancer. A colonoscopy was performed with the use of a magnifying videoscope, and an irregularity of the colonic wall at the transverse colon was detected (Panel A). The laterally spreading tumor became clear after a 0.2 percent indigo carmine solution was sprayed in the area (Panel B, arrows). A radiograph obtained after the administration of a double-contrast barium enema showed a flat, radiolucent area (Panel C, arrows). The patient underwent a laparoscopically assisted colectomy, and a tumor 5 cm in diameter was removed. Histologic examination showed invasion of the cancer in the submucosa, without invasion of the vessels or involvement of the lymph nodes (Panel D, hematoxylin and eosin). Follow-up after discharge was uneventful. After eight months, there has been no evidence of metastasis.

Darmblutung - Invagination

An 80-year-old woman presented with a three-day history of passage of bright red blood from the rectum. She was afebrile and had a blood pressure of 70/52 mm Hg. The white-cell count was 10,100 per cubic millimeter, and the hematocrit was 32.5 percent. An abdominal radiograph showed minimal ileus. A colonoscopy revealed blood in the colon and a round, smooth, violaceous lesion in the ascending colon that nearly obstructed the colonic lumen and that could not be passed by the colonoscope. A single computed tomographic image of the abdomen showed two views of an intussusception. In a cross-sectional view (arrowhead), traces of contrast medium in the intussusceptum (the invaginated segment of the colon) formed a high-density center, the swollen wall of the intussusceptum and mesenteric fat formed a crescentic low-density layer, and contrast medium in the intussuscipiens (the portion of the bowel into which the intussusceptum telescopes) formed the outermost, high-density layer. In a longitudinal view (arrow), the swollen bowel walls formed the thickened outer layer, and the intraluminal mesenteric fat and vessels formed a denser signal than did the intraluminal air in the loop of bowel just above it. At surgery, the terminal ileum was found to have prolapsed into the cecum and up the ascending colon.

Milzcyste

A 45-year-old man presented with a two-month history of discomfort in the left upper quadrant. Twenty years earlier, he had been involved in a motor vehicle accident. Physical examination confirmed mild tenderness over the posterior left upper quadrant. A plain abdominal film showed a large calcified lesion (Panel A, arrow) in the left upper abdomen. Computed tomography revealed a large, well-defined, cystic mass (8 by 9 by 11 cm) with mural calcification in the spleen (Panel B). Other causes of cystic splenic masses, such as parasitic cysts, various vascular tumors, fluid collections related to pancreatitis, benign tumors of the spleen, and cystic metastases, were ruled out.

Medizinisches Rätsel

A 62-year-old man presented with an ileus, marked abdominal distention, hypotension, and oliguria. He had a 15-year history of chronic psychosis. Laboratory findings included renal dysfunction, abnormal liver-function values, and marked hyponatremia. A total of 4800 ml of fluid was aspirated with a nasogastric tube. An anteroposterior abdominal radiograph revealed a ptotic gastric fundus filled with a very large, radiopaque density (arrows). What was responsible for the findings?

Leberhämangiom

A 46-year-old woman had a one-year history of abdominal distention. Physical examination showed an upper-abdominal mass extending from the right hypochondrium to 10 cm below the umbilicus. Laboratory studies disclosed thrombocytopenia (platelet count, 127,000 per cubic millimeter), prolongation of the prothrombin time (to 14.6 seconds), and a decrease in the fibrinogen level (to 80 mg per deciliter). The peripheral-blood smear showed anisocytosis. A computed tomographic scan showed a large, low-density mass in the right lobe of the liver (arrowhead), with prominent compression of the inferior vena cava (arrow). The patient underwent a right hepatic lobectomy. The mass was a cavernous hemangioma measuring 35 by 30 by 8 cm and weighing 4900 g. Three years after surgery, the patient was doing well and had not had a recurrence. Cavernous hemangioma is the most common benign hepatic tumor. It typically occurs in women. Lesions measuring more than 4 cm in diameter are known as "giant hemangiomas" and often cause symptoms such as vague abdominal distention and pain. The constellation of giant hemangioma, thrombocytopenia, and localized consumption coagulopathy is known as the Kasabach-Merritt syndrome.

The View from Space

Tony Delamothe, deputy editor, BMJ
tdelamothe@bmj.com
What would extraterrestrials make of life on earth if all they had to go on was this year’s Christmas BMJ? Such an event is not so unlikely. A corrupted line of computer code could easily beam the issue’s contents out to Alpha Centauri rather than on to readers’ iPads.
Given that so many articles focus on times past, extraterrestrials’ overwhelming impression might be that earthlings are happier looking backwards than forwards. The past may be another country, but that’s apparently where they prefer to live.
Setting the scene is the first editorial, which hymns a prelapsarian past before NHS managers seized the whip hand from doctors (doi:10.1136/bmj.e8239). Less fraught nostalgia is on offer in articles on the short lived genre of gastroscopic painting (doi:10.1136/bmj.e8323), how successive editions of a popular textbook charted changing obstetric fashions over the years (doi:10.1136/bmj.e8270), and an extraordinary series of drawings made in operating theatres (doi:10.1136/bmj.e8529).
Some articles mine the past explicitly for its relevance to the present. The editorial on hospital acquired infection draws parallels between the behaviour of contemporary British doctors and the Viennese obstetricians who made life difficult for Ignaz Semmelweis in the 19th century (doi:10.1136/bmj.e8330). Concerned extraterrestrials will be cheered that the problem of hospital infections is about to be solved, thanks to a combination of capes (doi:10.1136/bmj.e8286) and sniffer dogs (doi:10.1136/bmj.e7396).
Roger Kneebone and Abigail Woods have set about capturing the disappearing world of open surgery because they believe that such a record could prove useful after its practitioners have died out (doi:10.1136/bmj.e8135). Richard Smith looks to the stunningly successful British campaign to abolish slavery (1787-1807) as a model for tackling today’s seemingly intractable problems: the pandemic of non-communicable diseases, climate disruption, and global poverty (doi:10.1136/bmj.e8301).
Continuing the theme of mining the past to inform the present, two articles and an editorial examine the survival of Olympic athletes in the years following their triumph (doi:10.1136/bmj.e8308, doi:10.1136/bmj.e7456, doi:10.1136/bmj.e8338). The main aim of this trio is to ascertain whether being superfit increases one’s survival. Extraterrestrials could conclude that earth must be a great place to live if its inhabitants will consider doing anything so extreme to increase their time there.
Two papers look at the threats to healthy living. Simon Howard and colleagues compared meals cooked by television chefs with those of supermarkets’ own brands (doi:10.1136/bmj.e7607). On average, TV chefs’ meals had higher total fat, saturated fat, and sugar content than supermarket meals. No meal complied fully with WHO dietary recommendations. Jennifer Mindell and colleagues describe the insidious capture of the health promotion agenda in Britain by the private sector, aided and abetted by the current government (doi:10.1136/bmj.e8082). David Spiegelhalter despairs of the plethora of terms for quantifying the risks of lifestyle activities and suggests "microlives" as a more comprehensible alternative for those interested in living longer (doi:10.1136/bmj.e8223).
The journal ends with two articles of more than academic interest to alien readers. The first describes how, 50 years after earth sent a man into space, this opportunity is now available to anyone who can afford it (doi:10.1136/bmj.e8124). Given that many early customers will be old (in earth years), there’s likely to be a hike in the number of inflight emergencies; perhaps low flying extraterrestrials will be able to help out. We hope potential Good Samaritans will want to do so, after reading about the solicitous, if uncomprehending, care meted out to one of their number, mistakenly abandoned in suburban America (doi:10.1136/bmj.e8127).
Cite this as: BMJ 2012;345:e8605