Fluglärm macht krank ...

Mit der hier erhältlichen Broschüre “Jetzt mal ehrlich: Es reicht!” wenden sich achtzig Bürgerinitiativen aus dem gesamten Rhein-Main Gebiet an alle Bürger, die sich für Fortschritt und Schutz von Umwelt einsetzen und denen die Gesundheit und die Lebensqualität der Menschen in Frankfurt und in der Region ein besonderes Anliegen sind. Die Broschüre dient dem Zweck, umfassend über das Thema Flughafenausbau zu informieren und aufzuzeigen, welche Problematik sich aus 50% mehr Flugbewegungen ergäbe. Mehr

1:12

Trotz der Krise: Die Abzocker-Manager zahlen sich unverschämte Saläre und Millionen-Boni aus. Im Schnitt verdient ein Manager heute 4 Millionen oder 56 Mal mal mehr als ein/e normale/r Schweizer Arbeitnehmer/in! Dafür gehen sie erneut unverantwortliche Risiken ein, für die wir dann mit tieferen Löhnen, unseren Jobs oder unseren Steuern gerade stehen müssen. Die 1:12-Initiative schiebt hier einen Riegel. Mehr

Ich bin nicht wütend, sondern zornig ...

1813

In zwei Monaten stehen die Gedenkfeiern zum zweihundertsten Jahrestag der Völkerschlacht an. Schon jetzt aber gibt es in Leipzig selbst und in Dresden Präsentationen, die vor allem auf eines setzen: Anschaulichkeit. Mehr

We are killing people by not acting

Worldwide, lung cancer killed about 1·5 million people in 2010. Lung cancer has an extremely poor prognosis, with an overall 5 year survival of 16% in the USA and less than 10% in the UK. To achieve a substantial reduction in lung cancer mortality, global action and progress in prevention, early detection, and treatment are crucial. Mehr

Severe Sepsis and Septic Shock

A 77-year-old man is admitted to the intensive care unit (ICU) of a university hospital from the operating room. Earlier the same day, he had presented to the emergency department with abdominal pain. His medical history included treated hypertension and hypercholesterolemia, previous heavy alcohol intake, and mild cognitive impairment. In the emergency department, he was drowsy and confused when roused and was peripherally cold with cyanosis. The systemic arterial blood pressure was 75/50 mm Hg, and the heart rate was 125 beats per minute. The abdomen was tense and distended. After the administration of 1 liter of intravenous crystalloid to restore the blood pressure, a computed tomographic scan of the abdomen showed extraluminal gas and suspected extraluminal feces consistent with a perforated sigmoid colon. He was treated with intravenous antibiotics and taken to the operating room for laparotomy. During this procedure, gross fecal peritonitis from a perforated sigmoid colon was confirmed; resection of the sigmoid colon with closure of the rectal stump and creation of an end colostomy (Hartmann’s procedure) was performed with extensive peritoneal toilet and washout.

On arrival in the ICU, he is still anesthetized, the trachea is intubated, and the lungs are mechanically ventilated with a fraction of inspired oxygen of 0.4; the arterial blood pressure is supported with a norepinephrine infusion. When the patient was in the operating room, he received a total of 4 liters of crystalloid. On his arrival in the ICU, the vital signs are a blood pressure of 88/52 mm Hg, heart rate of 120 beats per minute in sinus rhythm, central venous pressure of 6 mm Hg, and temperature of 35.6°C. An analysis of arterial blood shows a pH of 7.32, a partial pressure of carbon dioxide of 28 mm Hg, a partial pressure of oxygen of 85 mm Hg, and a lactate level of 3.0 mmol per liter. 

Question

What therapy should be instituted to reduce this patient’s risk of dying from septic shock? Participate in the poll and, if you like, submit a comment supporting your choice. The editors’ recommendations will appear here, along with a link to the related review article, on August 29.

Mehr

Let's work together

Trish Groves, deputy editor, BMJ

tgroves@bmj.com

John Ioannidis, in a long and thoughtful interview in The Atlantic, was recently called a "dashing nerd" for his work as a meta-researcher: it was meant as a compliment (www.theatlantic.com/magazine/archive/2010/11/lies-damned-lies-and-medical-science/308269). His work couldn’t get much more meta than his current BMJ paper with US colleagues Konstantinos C Siontis and Tina Hernandez-Boussard (doi:10.1136/bmj.f4501).
They searched 2010’s PubMed for meta-analyses of randomised controlled trials on the effectiveness of interventions, randomly sampled 5% of them, searched with no date restriction for other potentially overlapping meta-analyses, and homed in on 20 clinical topics to assess the degree of redundancy. Two thirds of index meta-analyses had at least one partially or fully overlapping meta-analysis, few of them real updates. For instance, on statins for atrial fibrillation after cardiac surgery, there were 11 meta-analyses with similar eligibility criteria and overall results, albeit with a variety of included trials. The authors’ cautious conclusion is that "there might be some redundancy in published meta-analyses and waste of effort." Indeed.
David Moher’s linked editorial argues that, while there’s no magic number of meta-analyses, some judicious replication is required for drug regulation in different territories, and can increase clinicians’ and other decision makers’ confidence in the results (doi:10.1136/bmj.f5040). If all meta-analysts registered their protocols prospectively, ideally at the international registry PROSPERO (www.crd.york.ac.uk/NIHR_PROSPERO), and then followed the PRISMA reporting statement (www.prisma-statement.org), the evidence base would be in much better shape, says Moher. That’s why the BMJ asks authors to do both (www.bmj.com/about-bmj/resources-authors/article-types/research). Meanwhile, in rapid responses to the paper, Ingrid Mühlhauser and colleagues suggest a creative solution: design and perform each meta-analysis as a project by two independent working groups, planning replication right from the beginning (www.bmj.com/content/347/bmj.f4501/rr/656302). Indeed, that’s what the Multiparty Group for Advice on Science and the Cochrane Acute Respiratory Infections Group are doing right now with the individual participant data from Roche’s trials of oseltamivir—although the two groups got there by a much less collaborative route (http://blogs.bmj.com/bmj/2013/06/26/trish-groves-what-does-tamiflu-do-and-how-will-we-know).
Richard J Wassersug, cancer researcher, has been an individual participant in a trial (doi:10.1136/bmj.f4879). If we are serious about getting more patients to join clinical trials, he warns, we need to improve the language used in consent forms. The standard format includes pages where every paragraph begins with "You will," "You can," "You may," and so on, reviving for him the memory of a dressing down at school. "You realise how much trouble you are in? You hear me? You better not do that again! You understand? You better watch out!" Wassersug suggests much more inviting and friendly language, such as "If you join this study, we’ll be asking you to fill in a questionnaire on the side effects you experience," and signs off with "I hope you agree ... You better."
Cite this as: BMJ 2013;347:f5111

Choosing wisely

How can physicians and patients have the important conversations necessary to ensure the right care is delivered at the right time? Choosing Wisely® aims to answer that question.

An initiative of the ABIM Foundation, Choosing Wisely is focused on encouraging physicians, patients and other health care stakeholders to think and talk about medical tests and procedures that may be unnecessary, and in some instances can cause harm.

To spark these conversations, leading specialty societies have created lists of “Things Physicians and Patients Should Question” — evidence-based recommendations that should be discussed to help make wise decisions about the most appropriate care based on a patients’ individual situation. Mehr

Gemeinsam klug entscheiden

The dance of death

“So,” I asked, “how did it happen?”
“Well,” he said, “I was at a wedding and I got up to dance—that’s when I felt the pain in my chest.”
I was curious; for the third time in a matter of weeks a man in his 50s had had an infarct while at a wedding. The risk factors were obvious: overweight, unfit, suddenly hurled into intense physical activity, but could there be something more going on, something sinister?  Mehr

Laparoscopic cholecystectomy: first, do no harm; second, take care of bile duct stones

A bile duct injury (BDI) rate of 0.2 % was reported in the era when open cholecystectomy (OC) was the standard [5]. Currently, LC BDI rates ranging from 0.2 to 0.5 % are more the norm in large population-based studies [6–9]. Although the laparoscopic BDI rate may be lessening with the passage of time, BDI is still more likely with LC than with OC, and remains a real danger in the learning curve of every surgeon [10].
Mehr

Laparoscopic versus open surgery for rectal cancer (COLOR II): short-term outcomes of a randomised, phase 3 trial

n In selected patients with rectal cancer treated by skilled surgeons, laparoscopic surgery resulted in similar safety, resection margins, and completeness of resection to that of open surgery, and recovery was improved
after laparoscopic surgery. Results for the primary endpoint—locoregional recurrence—are expected by the end of 2013. Mehr

Measuring hospital clinical outcomes

The proliferation of information about hospital performance is a cause for consternation. We are drawn to data about performance, yet we are wary of their accuracy and reliability. We want information about the results that our acute care organizations achieve, yet we are often skeptical about whether what is important in medicine can be measured well. Mehr

Hoheit hält im Sommer Hof

Ausgesprochen schön, aber auch anspruchsvoll und kapriziös - Rosen fordern einen Gärtner heraus. Damit sie richtig zur Geltung kommt, braucht die Königin der Blumen passende Begleiter.
Mehr

Saving Lives: Frontline Medicine in a Century of Conflict

This free exhibition uses personal stories to examine all aspects of medical care on the front line, from the trenches of the First World War to present-day Afghanistan.

Saving Lives looks at the physical and emotional impact on individuals in fighting wars and the wider consequences for society. Follow a casualty through the medical chain, from the battlefield to field hospitals and on to specialist care at home.

Ever wondered how medics cope under fire? In interviews specially commissioned for the exhibition, nurses, surgeons and soldiers - as well as volunteers from the local 207 (Manchester) Field Hospital - speak about the motivations and experiences of medics who serve on the front line.

From routine health to battlefield casualties and treating disease, find out how military medicine has evolved across a century of conflict and helped shape the medical care we receive today. Mehr

Gottes tausend Dukaten

Lejzr-Gabe ist der Diener von Reb Naftuli, und einmal ist er traurig.
Was hast du? fragt ihn der Rabbi.
Einen Streit habe ich, mit Gott dem Herrn. Ich habe zu Gott dem Herrn gesagt: Unser Rebbe sagt, dass vor dir, Herr, tausend Jahre sind wie ein Augenblick. Und ich, Lejzr-Gabe, sage, das tausend Dukaten vor dir sind wie ein Dukat. Herr im Himmel, was kann es dir da ausmachen, wenn du mir, dem Lejzr, einen deiner Dukaten gibst?
Und was, fragt der Rabbi, hat Gott der Herr gesagt?
Gott der Herr hat gesagt: Lejzr-Gabe, gedulde dich einen Augenblick.

Jakob Hessing
FAZ Mittwoch 24 Juli 2013 Nr 169 Seite 26

Öfen für alle

Hätte Anne Odhiambo einen Ofen, dann müsste sie statt fünf Stunden nur noch eine Stunde kochen. In der gesparten Zeit könnte sie in ihrem Dorf Marenyo im Westen Kenias arbeiten. Die Armen dieser Welt würden allein durch den Besitz von Öfen jeden Tag hochgerechnet Hunderte Millionen Arbeitsstunden gewinnen. Mehr

Die Wahl gestern bei "En Haufe Leut ..." - In Hessen und im Bund siegen SPD und Grüne

Gestern Abend im Kabaret "En Haufe Leut" ...
Lothar Mark wie gewohnt souverän in der Premierenvorstellung, ausverkauftes Haus!
Er läßt sich das natürlich nicht entgehen - eine Landes- und Bundestagswahl durchzuführen.
Ergebnis: sowohl in Hessen wie im Bund gewinnen SPD und Grüne, die FDP ist draussen ...

Myths, Presumptions, and Facts about Obesity

Passionate interests, the human tendency to seek explanations for observed phenomena, and everyday experience appear to contribute to strong convictions about obesity, despite the absence of supporting data.
When the public, mass media, government agencies, and even academic scientists espouse unsupported beliefs, the result may be ineffective policy, unhelpful or unsafe clinical and public health recommendations, and an unproductive allocation of resources. In this article, we review some common beliefs about obesity that are not supported by scientific evidence and also provide some useful evidence-based concepts. We define myths as beliefs held to be true despite substantial refuting evidence, presumptions as beliefs held to be true for which convincing evidence does not yet confirm or disprove their truth, and facts as propositions backed by sufficient evidence to consider them empirically proved for practical purposes. Mehr

Neue Leitlinie zur chronischen Pankreatitis

Obwohl die meisten Patienten mit chronischer Pankreatitis ambulant behandelt werden, erfolgen allein in Deutschland jährlich 10.267 Krankenhausaufnahmen bei Vorliegen einer chronischer Pankreatitis (ICD-10:K86, statistisches Bundesamt für 2008). Ein Drittel der Patienten, die an einer chronischen Pankreatitis leiden, können ihren erlernten Beruf nicht mehr ausüben und 40% werden wegen ihrer Erkrankung arbeitsunfähig oder berentet. Die Sterblichkeit der Erkrankung ist gegenüber der Normalbevölkerung 3,6-fach erhöht Mehr

Pulmonary Sequestration

A 9-year-old boy with a history of a lung lesion suspected to be a pulmonary sequestration or a congenital cystic adenomatoid malformation presented to the emergency department with fever and chest pain.
A chest radiograph (Panel A) showed a large opacity in the right lung, abutting the minor fissure and displacing it downward. Mehr

Selection Criteria for Lung-Cancer Screening

The National Lung Screening Trial (NLST) showed that lung-cancer screening with the use of low-dose computed tomography (CT) resulted in a 20% reduction in mortality from lung cancer.1  Some organizations now recommend adoption of lung-cancer screening in clinical practice for high-risk persons if high-quality imaging, diagnostic methods, and treatment are available.2-4 Most of these recommendations identify persons to be screened by applying the NLST criteria, which include an age between 55 and 74 years,
a history of smoking of at least 30 pack-years, a period of less than 15 years since cessation of smoking, or some variant of these criteria. Mehr

Viewpoint - Sepsis definitions: time for change

For the Ancient Greeks, sepsis referred to rot, decay, or putrefaction. Galen and Celsus described the signs of  infl ammation as peripheral vasodilatation (rubor), fever (calor), pain (dolor), increased capillary permeability (tumor), and organ dysfunction (functio laesa) 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

Transanal hybrid colon resection: from laparoscopy to NOTES

Natural orifice transluminal endoscopic surgery (NOTES) has stimulated centers around the world to assess various possibilities to transform this new idea from the experimental setting into clinical practice [1]. Experimental technical feasibility has been determined for several indications, including cholecystectomy and bowel resection. In patients, the transvaginal approach has been used most frequently in the past, usually for transvaginal cholecystectomy [2]. Initial experimental experience has been gathered with transvaginal and transanal colorectal procedures [3–7]. Worldwide, very few centers have begun applying this technique in patients; when performed, it is mostly for transanal rectal resection [8, 9]. Mehr

Women who smoke like men, die like men

Smoking has become substantially riskier for women during the past 50 years, say researchers. Analyses from two historical and five contemporary US cohorts suggest that the risks for women are now about the same as they are for men. Smokers of both sexes are now about 25 times more likely than never smokers to die of lung cancer, between 22 and 25 times more likely to die of chronic obstructive pulmonary disease (COPD), and nearly three times more likely to die of ischaemic heart disease. Mehr

Aussergrubhof wir kommen ...

Unser Bauernhof liegt auf 1550 Metern Meereshöhe auf der Sonnenseite des Ultentales, auf halber Höhe des Dörfchens St. Nikolaus und des Ski- und Wandergebietes Schwemmalm. Unser Bauernhof wird seit Generationen von unserer Familie bewirtschaftet. Wir sind in der Forst- und in der Viehwirtschaft tätig. Unser Stall beherbergt Kühe, Kälber, Schweine und Hühner, um's Haus streuen unsere Katzen. Der Aussergrubhof liegt abseits von Strassen und Verkehr, stolz und erhaben inmitten seiner eigenen Wiesen, Felder und Wälder, welche sich vom Hof bis hin zu unserer Alm, der "Inneren Schwemmalm" (2050 ü.d.M.) erstreckt. Mehr

Und noch mehr ...

Altötting - Zu Besuch bei der Schwarzen Madonna

Zum dritten Mal in Altötting - das erste Mal als kleiner Junge mit meiner Mutter zur Wallfahrt, das zweite Mal als junger Assistent zu Besuch beim Bayerischen Chirurgenkongress ... das Wetter war herrlich wie jetzt, und das Bier und die Weisswürste schmeckten  genauso gut wie damals.
Grund genug, sich bei der Schwarzen Madonna zu bedanken und für einen Freund um Hilfe zu bitten.



Mehr

Impact of wound edge protection devices on surgical site infection after laparotomy: multicentre randomised controlled trial (ROSSINI Trial)

Conclusions Wound edge protection devices do not reduce the rate of surgical site infection in patients undergoing laparotomy, and therefore their routine use for this role cannot be recommended.

Mehr

First do not harm

First do no harm

Fiona Godlee, editor, BMJ

fgodlee@bmj.com

Most countries in the world have heeded the World Health Organization’s call to include hepatitis B vaccine in childhood immunisation programmes. But six countries in Northern Europe, including the United Kingdom, have not. Why are they holding out? Hepatitis B infects two billion people worldwide, causing hundreds of millions of chronic infections and early deaths from liver disease. About 14 million people in Europe are chronically infected.
Such high numbers help Pierre Van Damme and colleagues make a good case for the remaining six European countries to fall into line (doi:10.1136/bmj.f4057). The alternative approaches—targeting people at high risk and preventing perinatal transmission—are hard to implement, they say. But Tuija Leino and colleagues argue persuasively against universal vaccination in these non-endemic countries. They explain that the main aim of hepatitis B prevention is to stop people becoming carriers. Most infections in low endemicity countries occur in young adults, among whom rates of lifelong virus carriage are less than 5%. Immigration is the main source of new carriers in these countries, and childhood vaccination would have minimal impact on the prevalence of carriers, they say. Better to focus efforts on effective programmes for antenatal hepatitis B screening. Last week’s editorial on hepatitis B in China summarised the current best options for interrupting mother to child transmission in infected women (BMJ 2013;347:f4503).
The tendency to favour universal prevention programmes is questioned elsewhere in the journal this week. The UK government recently announced that all adults aged 40-75 will be offered regular free health checks. On the face of it, this sounds like a good and generous plan. But Felicity Goodyear-Smith asks: "do benefits outweigh harms, do false negatives lead to inappropriate reassurance, or do false positives lead to over-investigation and over-intervention?" (doi:10.1136/bmj.f4788). Screening always comes with social and financial costs, she says. With primary care services already heavily stretched, this latest government initiative doesn’t sound like good medicine or good value for money.
Nor does the new catch all definition of chronic kidney disease. Continuing our series on overdiagnosis, Ray Moynihan and colleagues explain that the large numbers of people now labelled as having chronic kidney disease (14% of all adults), combined with the low rate of total kidney failure, suggests that many of those diagnosed will never develop symptoms (doi:10.1136/bmj.f4298). The authors recommend clinical scepticism about the current definition and call for caution in labelling patients, especially older people.
What then of plain packaging for cigarettes? Here’s an intervention that seems poised to improve public health. As Crawford Moodie and colleagues recount, Australia’s experiment continues apace and the growing body of research is consistent in finding that plain packaging would reduce the appeal of tobacco products, particularly among children (doi:10.1136/bmj.f4786). Research also suggests that it would make health warnings more effective and make it harder for manufacturers to mislead smokers about the risks. So what’s stopping other governments from following Australia’s lead? Not an absence of good evidence but a lack of political will.
Cite this as: BMJ 2013;347:f4843