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Interactive Medical Cases

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Eine Anleitung zum Glücklichsein ...

Das Gesetz der kleinen Zahl: Wie wir permanent hereingelegt werden...

Sie sitzen in der Konzernleitung eines Einzelhandelsunternehmens mit 1000 Filialen. Ein Berater, der im Auftrag des Finanzchefs eine Studie zum leidigen Thema Ladendiebstahl durchgeführt hat, präsentiert seine Ergebnisse. Gross auf der Leinwand prangen die Namen der 100 Filialen mit den grössten Diebstahlraten - in Prozent des Umsatzes. Darüber steht in dicken Buchstaben die erstaunliche Erkenntnis: «Die Filialen, in denen am meisten gestohlen wird, liegen vorwiegend in ländlichen Gebieten.» 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

Pneumonie auf der Intensivstation

Beyond Pneumonia by Prof Dr Dr Ernst Hanisch

Predicting Death for Patients With Abdominal Septic Shock

This paper reports the result of the MEDAN project that analyzes a multicenter septic shock patient data collection. The mortality prognosis based on 4 scores that are often used is compared with the prognosis of a trained neural network. We built an alarm system using the network classification results. Method. We analyzed the data of 382 patients with abdominal septic shock who were admitted to the intensive care unit (ICU) from 1998 to 2002. The analysis includes the calculation of daily sepsis-related organ failure assessment (SOFA), Acute Physiological and Chronic Health Evaluation (APACHE) II, simplified acute physiology score (SAPS) II, multiple-organ dysfunction score (MODS) scores for each patient and the training and testing of an appropriate neural network. Results. For our patients with abdominal septic shock, the analysis shows that it is not possible to predict their individual fate correctly on the day of admission to the ICU on the basis of any current score. However, when the trained network computes a score value below the threshold during the ICU stay, there is a high probability that the patient will die within 3 days. The trained neural network obtains the same outcome prediction performance as the best score, the SOFA score, using narrower confidence intervals and considering three variables only: systolic blood pressure, diastolic blood pressure and the number of thrombocytes. We conclude that the currently best available score for abdominal septic shock may be replaced by the output of a trained neural network with only 3 input variables.

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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

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?

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

Gluten Sensitivity?

Fiona Godlee, editor, BMJ
fgodlee@bmj.com
Does non-coeliac gluten sensitivity exist? The author of this week’s Patient Journey has no doubt of it (doi:10.1136/bmj.e7982). After years of unexplained ill health, a chance conversation on an internet forum led him to try an exclusion diet. The results were dramatic, he says. "Within a week of excluding gluten and lactose from my diet, all my symptoms had dramatically improved in just the same way as when I previously starved myself." Accidental rechallenge brought the symptoms back "within hours."
Despite symptomatic relief he wanted a "proper diagnosis." He saw Kamran Rostami, whose account of the condition accompanies the patient’s story. "Patients have negative immunoallergy tests to wheat and negative coeliac serology; normal endoscopy and biopsy; symptoms that can overlap with coeliac disease, irritable bowel syndrome, and wheat allergy." Symptoms resolve on a gluten-free diet. Since there are no biomarkers, gluten sensitivity is the ultimate diagnosis of exclusion.
This, and the lack of a disease mechanism, may explain why not everyone is convinced. Luca Elli would like to see aspects of gluten sensitivity clarified before we start "treating" people for this new "disease" (doi:10.1136/bmj.e7360). He argues that although exclusion diets aim to improve patients’ quality of life, they also in themselves reduce quality of life, and we don’t know about possible complications. And what of the financial incentives for companies promoting gluten-free products? The worldwide market is now estimated to be worth up to $850m a month. Is gluten sensitivity different from irritable bowel syndrome, asks Elli, or is it simply a variant that benefits from a common therapeutic approach?
Imran Aziz and colleagues look to the published literature to resolve these uncertainties (doi:10.1136/bmj.e7907). Compared with coeliac disease, gluten sensitivity has been little researched, but a few randomised trials suggest that this is a real condition, affecting 6% of nearly 6000 people tested in a Maryland clinic. The worldwide shift to the Mediterranean diet may explain the rising prevalence, they say. A multicentre trial is currently recruiting people with gluten sensitivity for challenge with gluten or placebo. Meanwhile, these authors advise that patients in whom coeliac disease has been excluded through serology tests and duodenal biopsy should be told that their problem is a newly recognised clinical entity for which we do not yet fully understand the natural course or pathophysiology.
This advice will contribute further to the rising number of people being tested for coeliac disease. In a letter published this week, David Unsworth and colleagues report on the "explosion of requests" for serological testing since 2007, particularly from primary care (doi:10.1136/bmj.e8120). NICE guidance in 2009 did little to check the rise, they say. And as the number of people being tested has risen, the proportion of those in whom coeliac disease is confirmed has fallen to just over 1%, no better than would be achieved by random screening. They call for more targeted testing, limited to groups in whom detection rates are highest: children with failure to thrive, family history, or type 1 diabetes, and adults attending diabetes and gastroenterology clinics. This makes sense, except that detection rates are not the only way to judge the value of a test. As our Patient Journey shows, a negative test result can be just as valuable to the patient.
Cite this as: BMJ 2012;345:e8450

Moderater Alkoholgenuss schützt vor Krankheiten...

...Assuming there is no previous history of alcohol abuse, moderate alcohol consumption is now accepted as reducing all-cause and cardiovascular mortality, and it also can reduce the incidence of certain diseases. The metabolic changes produced by moderate alcohol consumption include increased circulating levels of adiponectin, high-density lipoprotein cholesterol, apolipoprotein A1 and C-reactive protein, as well as decreased levels of fibrinogen, but clear-cut connections to any of the protective effects of alcohol remain to be established. Mehr

At a Loss...

A 31-year-old woman presented to the emergency department with an 8-month history of nausea and episodic epigastric pain that was accompanied by fatigue, headache, loss of appetite, and loose stools. During a review of systems, she also noted numbness and tingling in both hands and both feet, as well as difficulty walking for the past 3 months. She reported no fever, muscle weakness . . .Mehr

Patient With a Rash, Abdominal Pain, and Weight Loss

A 49-YEAR-OLD MAN PRESENTS WITH RIGHT ILIAC FOSSA PAIN OF 36 HOURS’
duration. He reports loss of appetite, weight loss, and increasing lethargy over the preceding 10 months with intermittent constipation but no other symptoms. Mehr

Handreichungen zur Selbstheilung

...Hatte man lange geglaubt, dass man nur etwas "wollen" muss, um eine Verhaltensänderung zu erzielen, so hat uns die moderne Hirnforschung eines Besseren belehrt. Zu mehr als neunzig Prozent sind es Gefühle und unbewusste Prozesse, die unseren Körper steuern...
Rober Jütte
FAZ 24. Januar 2012, Nr 20 Seite 30

Stalking the diagnosis

...This case illustrates an unusual presentation of breast cancer — that is, metastasis to the pituitary gland. In retrospect, the patient presented with a number of typical symptoms and signs of hypopituitarism, including weakness, intermittent nausea, orthostasis, polydipsia, and polyuria. Her fever and positive urine culture, as well as her dysphagia and dry mouth, initially distracted the clinicians from a consideration of the primary disease process. The recognition of the hormonal deficiencies caused by a lesion on the pituitary stalk and the reconciliation of these developments with the diffuse lymphadenopathy led to the definitive diagnosis that unified this seemingly incongruent set of clinical findings.
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Blaue Skleren

A 60-year-old man with a history of multiple fractures after minor trauma presents for evaluation of anemia with a hemoglobin level of approximately 9 g/dL. Other medical problems include chronic hypertension and worsening chronic kidney disease (CKD). His family history is remarkable for short stature and dental problems. Physical examination reveals a short male with blue sclerae (Figure). Iron levels are normal and ferritin is elevated. A kidney biopsy performed for renal dysfunction progressing more rapidly than expected reveals glomerulosclerosis compatible with hypertensive nephropathy. A bone marrow biopsy is negative for malignancy and shows elevated iron levels.

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