2013 Issue

The Medicalisation of Criminal Behaviour: A Unifying Approach

doi:10.7244/cmj.2013.12.001
J Rogers

Phèdre is a tragedy which explores the relationship between moral culpability and responsibility for one’s actions by examining the incestuous love of a queen for her step-son, a passion that is apparently imputed to her by a vengeful deity. What is fascinating for the purposes of our discussion is the dynamic interplay between the portrayals of Phèdre’s infatuation both as an illness and simultaneously as a crime, for this is essentially the same question we must consider in deciding to what extent a malady excuses behaviour that contravenes society’s judicial expectations. While this was doubtless an intriguing consideration for a seventeenth century French dramatist, it is all the more pertinent for us today given the extent of medicalisation that has occurred in recent decades across many spheres of society.

Case Report: Left knee pain in a young female athlete

doi:10.7244/cmj.2013.11.002
Jonathan Packer

A 14 year old girl was seen in clinic after an injury whilst playing rugby. Although her description was vague, she intimated that a valgus stress had been put on her left leg and described being tackled in rugby practice. She fell on her left knee and heard an audible cracking or ‘pop’ sound, experiencing immediate pain and swelling of the joint. She had no significant past medical history and was taking no regular medication.

Detection of Coeliac Patients at Risk of an Osteoporotic Fracture: A Two-Cycle Clinical Audit

doi:10.7244/cmj.2013.11.001
A Nunn, D Patterson

Patients diagnosed with Coeliac disease are known to be at higher risk of suffering a low-impact fracture, and even as children it is important to detect and correct malabsorption due to Coeliac since this may have a lasting impact on their lifelong fracture risk. The British Society of Gastroenterologists recommends that those Coeliac patients with two or more additional risk factors for osteoporotic fracture undergo a dual X-ray absorptiometry (DEXA) scan to determine their bone density. This audit addressed the question of whether this standard was being adhered to in a general practice setting in the south-east of England. The capture of cases represented a prevalence of 1:275 (similar to previously reported figures for the prevalence of this condition). The rate of DEXA scanning in this population was disappointingly low (only 37%), and since many of those Coeliac patients who should have been scanned, and were not, possessed ‘minor’ risk factors such as smoking or female gender, the low pick-up rate may be attributable to a lack of awareness of the small but significant risk that these factors pose. Of those DEXA scans performed, the bone mineral densities of the patients concerned was inversely proportional to the number of risk factors they possessed, supporting the stance of the BSG. Practitioner education alone was not sufficient to improve the rate of scanning, which actually declined following a period of raising awareness of the need for such scans.

Review: Complete Revision Notes for Medical And Surgical Finals (2nd edition)

doi:10.7244/cmj.2013.10.002
Charleen Chan Wah Hak

Initially, I had my doubts on the ambitious title of this book, which made it sound as if it were going to be an incredible task to read. Instead, it was pleasantly surprising to find it very readable with a simple layout, readable typeface, simple illustrations and a smattering of key radiographs throughout. All specialities are covered comprehensively in a system-based format, including a Public Health chapter and a Symptom control / palliative care section under Oncology.

An Anaesthetic Muse(um)

Image credit: Garrett Coakley

doi:10.7244/cmj.2013.10.001
Jonathan Dauncey

Proclaiming it possesses the historical magnitude of the Natural History Museum or the g-forces created by the Typhoon Jet simulator in the Science Museum is perhaps overstepping the mark. However, the Anaesthesia Museum in London is certainly worth an hour of your time if you ever find yourself shimmying the droves of wide-eyed cash-flashers on Oxford Street. Equidistant between Oxford Circus and Regent’s Park tube stations, the museum boasts over 3000 anaesthetic items from throughout the anaesthetic ages. It is a must-visit for those curious about the origins of a speciality that was conceived by plucky medics taking turns at inhaling mystical concoctions of unidentified gases that lined their 19th century labs in a quest to eliminate pain [1]

Jacksonian seizure: A trembling thought

doi:10.7244/cmj.2013.09.001
TB Stoker, AMH Young, AY Allan, SR Large

Case presentation: A 22 year old male with a 3-year history of impaired left ventricular function and a past medical history of anthracycline-treated acute myeloid leukaemia was admitted with symptoms of worsening cardiac failure. The patient’s symptoms progressed over 3 months, and included diminished exercise tolerance, orthopnoea, paroxysmal nocturnal dyspnoea, nausea, abdominal pain and diarrhoea. He also described an acute nocturnal episode of severe chest pain, shortness of breath, and involuntary twitching, beginning in the left hand and progressing proximally. The patient was diagnosed with dilated cardiomyopathy – a well-documented side effect of anthracycline therapy.

A case of a single coronary artery arising from the right coronary cusp

doi:10.7244/cmj-1379800800
Laura Skinner

Coronary artery anomalies (CAAs) are present in 1-1.96% of the population [1,2]. The clinical significance of single CAAs differs depending on the course of the artery. Those that take an inter-arterial (malignant) course, between the aorta and pulmonary artery, can present with syncope or sudden death [1,3]. This is attributed to the myocardial ischaemia that ensues when the single coronary artery is compressed between high-flow structures in systole. Whereas, those that traverse benign, inter-ventricular paths do not predispose to myocardial ischaemia, hence, patients are often asymptomatic [1,3]

The Unconsidered Differential Diagnosis of Recurrent Acute Abdomen

doi:10.7244/cmj-1379800800-1
Shirley Sze

A 32-year-old from Turkey (Kurdistan province) presented with a 4-year history of recurrent, severe, vague abdominal pain requiring numerous hospitalizations. The pain was non-radiating, dull and constricting in nature with acute onset. There were no associated symptoms apart from constipation. His C-reactive protein and white cell count were always raised during these acute episodes. The pain resolved spontaneously without any specific treatment. He was completely well in between these acute episodes. Investigations including diagnostic laparoscopy, endoscopy and colonoscopy, CT scans and porphyria and infection screens were performed and were found to be negative / normal. Subsequent analysis of the MEFV gene detected two pathogenic variants (Met680IGC and Glu148Gln) on exon 2 and 10 and a diagnosis of familial Mediterranean fever was made. He had no further acute episodes after colchicine treatment was initiated.

It’s all in the Head?

doi:10.7244/cmj-1379800800-0
Lisa Sabir

Mr F, a Maltese 69 year old retired electrician living at home with his wife, presented to the Emergency Department with a referral from his ophthalmologist. Mr F presented with a two month history of headaches that had worsened the last two weeks accompanied by a deterioration in peripheral vision over the last week. The headache was described as continuous and generalised, had suddenly increased in severity from 2/10 to 7/10 over the last 2 weeks, and was not affected by posture, movement or time of day. Mr F denied any associated vomiting, drowsiness, neck stiffness, photophobia or rhinorrhoea. Other clinical features noted were fatigue, cold intolerance, decreased need for shaving and decreased libido for the past month. No other constitutional symptoms including weight loss, change in appetite, fevers, or night sweats were reported. No changes in bladder or bowel function.

Safety of SSRIs in Pregnancy

Image credit: tipstimes.com/pregnancy

doi:10.7244/cmj.2013.07.003
Sian-Lee Ewan

A recent study, Jensen et al 2013 [1], sought to differentiate the effects of exposure to maternal depression from the effects of antidepressants in their contribution to a reduction of Apgar scores. They collected data regarding diagnosis of depression, use of antidepressants in pregnancy, and Apgar scores at 5 minutes from all pregnancies in Denmark from 1996 to 2006 using national databases. This gave information on 668,144 births. Pregnant women were divided into 8 risk groups depending on their exposure to antidepressants during pregnancy, their exposure to antidepressants before pregnancy, and a diagnosis of depression before the end of pregnancy. Logistic regression analyses were applied with Apgar score <7 as the outcome and risk group as the variable of interest. Apgar score of <7 at 5 minutes was used as the outcome because it has been associated with an increased risk of low IQ at age 18, individuals being less likely to have no income from work, and neurological disability [1]

Medical Students concerned regarding lack of research skill teaching

Image credit: Bryan Jones

doi:10.7244/cmj-1373989392
F Cooksey, R Smith, TI Lemon, R Sharm, A Yarrow Jenkins, P Winter, A Buick

Knowledge of research skills and methods, once an integral part of the academic process, has in recent times become neglected by medical schools. Anecdotal evidence suggests political pressures have prioritised communication skills training as the focus towards producing the best doctors for tomorrow. Consequently, the prioritisation of communication training in the UK undergraduate curriculum has caused a reduction in research methods training, despite Tomorrows Doctors (2009) [1] documenting research skills such as critical appraisal integral to the analytical armoury of the developing clinician. We decided to poll students as to whether they felt they are adequately taught research skills and methods in their undergraduate medical courses.

Short-term vs Conventional Glucocorticoid Therapy in Acute Exacerbations of COPD

Image credit: Hey Paul Studios

doi:10.7244/cmj.2013.07.002
Christine Ma

Three hundred and fourteen patients >40 years old with >20 pack year history and diagnosed acute exacerbation of COPD in hospital were randomised to have either 5 or 14 days of systemic glucocorticoids. The primary end point of this study was the time to next exacerbation over a follow-up period of 6 months, and secondary end points examined all-cause mortality, changes in pulmonary function testing, clinical performance, glucocorticoid-associated adverse events. Apart from a higher cumulative glucocorticoid exposure in the 14 day therapy group, there were no statistical differences in primary or secondary outcome measures between the two groups.

'To Give or Not to Give'

Image credit: scribbletaylor

doi:10.7244/cmj.2013.07.001
Shannon Leckey, Thomas Lemon

In order to be passed, the draft bill must first be introduced into the assembly, go through all 4 stages of scrutiny and then be presented for Royal Assent. Ministers aim for the law to be in place by 2015.As medical students, we should all know about the legal regulations surrounding key aspects of medicine, The Welsh Government published the Draft Human Transplantation Act in June 2012 [1]. It proposes that Welsh residents give presumed consent for organ donation unless they ‘opt out’ of the system

CABG superior to PCI for diabetic patients with multi-vessel CAD

Image credit: Charlie J

doi:10.7244/cmj.2013.06.001
Clement Loh Chee Hoou

Coronary artery disease (CAD) affects millions worldwide. In North America, nearly 700,000 people are diagnosed with multi-vessel CAD and require immediate revascularisation and of these, 200,000 are diabetic. Coronary artery bypass graft (CABG) surgery or percutaneous coronary intervention (PCI) are the two main modalities of revascularisation. The previous BARI, CARDia, TAXUS and SYNTAX randomised clinical trials offered conclusive evidence favouring CABG over PCI as the preferred method of revascularisation (1).

An Anaesthetic Muse(um)

Image credit: Garrett Coakley

doi:10.7244/cmj.2013.10.001
Jonathan Dauncey

Proclaiming it possesses the historical magnitude of the Natural History Museum or the g-forces created by the Typhoon Jet simulator in the Science Museum is perhaps overstepping the mark. However, the Anaesthesia Museum in London is certainly worth an hour of your time if you ever find yourself shimmying the droves of wide-eyed cash-flashers on Oxford Street. Equidistant between Oxford Circus and Regent’s Park tube stations, the museum boasts over 3000 anaesthetic items from throughout the anaesthetic ages. It is a must-visit for those curious about the origins of a speciality that was conceived by plucky medics taking turns at inhaling mystical concoctions of unidentified gases that lined their 19th century labs in a quest to eliminate pain [1]

Jacksonian seizure: A trembling thought

doi:10.7244/cmj.2013.09.001
TB Stoker, AMH Young, AY Allan, SR Large

Case presentation: A 22 year old male with a 3-year history of impaired left ventricular function and a past medical history of anthracycline-treated acute myeloid leukaemia was admitted with symptoms of worsening cardiac failure. The patient’s symptoms progressed over 3 months, and included diminished exercise tolerance, orthopnoea, paroxysmal nocturnal dyspnoea, nausea, abdominal pain and diarrhoea. He also described an acute nocturnal episode of severe chest pain, shortness of breath, and involuntary twitching, beginning in the left hand and progressing proximally. The patient was diagnosed with dilated cardiomyopathy – a well-documented side effect of anthracycline therapy.

A case of a single coronary artery arising from the right coronary cusp

doi:10.7244/cmj-1379800800
Laura Skinner

Coronary artery anomalies (CAAs) are present in 1-1.96% of the population [1,2]. The clinical significance of single CAAs differs depending on the course of the artery. Those that take an inter-arterial (malignant) course, between the aorta and pulmonary artery, can present with syncope or sudden death [1,3]. This is attributed to the myocardial ischaemia that ensues when the single coronary artery is compressed between high-flow structures in systole. Whereas, those that traverse benign, inter-ventricular paths do not predispose to myocardial ischaemia, hence, patients are often asymptomatic [1,3]

The Unconsidered Differential Diagnosis of Recurrent Acute Abdomen

doi:10.7244/cmj-1379800800-1
Shirley Sze

A 32-year-old from Turkey (Kurdistan province) presented with a 4-year history of recurrent, severe, vague abdominal pain requiring numerous hospitalizations. The pain was non-radiating, dull and constricting in nature with acute onset. There were no associated symptoms apart from constipation. His C-reactive protein and white cell count were always raised during these acute episodes. The pain resolved spontaneously without any specific treatment. He was completely well in between these acute episodes. Investigations including diagnostic laparoscopy, endoscopy and colonoscopy, CT scans and porphyria and infection screens were performed and were found to be negative / normal. Subsequent analysis of the MEFV gene detected two pathogenic variants (Met680IGC and Glu148Gln) on exon 2 and 10 and a diagnosis of familial Mediterranean fever was made. He had no further acute episodes after colchicine treatment was initiated.

It’s all in the Head?

doi:10.7244/cmj-1379800800-0
Lisa Sabir

Mr F, a Maltese 69 year old retired electrician living at home with his wife, presented to the Emergency Department with a referral from his ophthalmologist. Mr F presented with a two month history of headaches that had worsened the last two weeks accompanied by a deterioration in peripheral vision over the last week. The headache was described as continuous and generalised, had suddenly increased in severity from 2/10 to 7/10 over the last 2 weeks, and was not affected by posture, movement or time of day. Mr F denied any associated vomiting, drowsiness, neck stiffness, photophobia or rhinorrhoea. Other clinical features noted were fatigue, cold intolerance, decreased need for shaving and decreased libido for the past month. No other constitutional symptoms including weight loss, change in appetite, fevers, or night sweats were reported. No changes in bladder or bowel function.

Safety of SSRIs in Pregnancy

Image credit: tipstimes.com/pregnancy

doi:10.7244/cmj.2013.07.003
Sian-Lee Ewan

A recent study, Jensen et al 2013 [1], sought to differentiate the effects of exposure to maternal depression from the effects of antidepressants in their contribution to a reduction of Apgar scores. They collected data regarding diagnosis of depression, use of antidepressants in pregnancy, and Apgar scores at 5 minutes from all pregnancies in Denmark from 1996 to 2006 using national databases. This gave information on 668,144 births. Pregnant women were divided into 8 risk groups depending on their exposure to antidepressants during pregnancy, their exposure to antidepressants before pregnancy, and a diagnosis of depression before the end of pregnancy. Logistic regression analyses were applied with Apgar score <7 as the outcome and risk group as the variable of interest. Apgar score of <7 at 5 minutes was used as the outcome because it has been associated with an increased risk of low IQ at age 18, individuals being less likely to have no income from work, and neurological disability [1]

Medical Students concerned regarding lack of research skill teaching

Image credit: Bryan Jones

doi:10.7244/cmj-1373989392
F Cooksey, R Smith, TI Lemon, R Sharm, A Yarrow Jenkins, P Winter, A Buick

Knowledge of research skills and methods, once an integral part of the academic process, has in recent times become neglected by medical schools. Anecdotal evidence suggests political pressures have prioritised communication skills training as the focus towards producing the best doctors for tomorrow. Consequently, the prioritisation of communication training in the UK undergraduate curriculum has caused a reduction in research methods training, despite Tomorrows Doctors (2009) [1] documenting research skills such as critical appraisal integral to the analytical armoury of the developing clinician. We decided to poll students as to whether they felt they are adequately taught research skills and methods in their undergraduate medical courses.

Short-term vs Conventional Glucocorticoid Therapy in Acute Exacerbations of COPD

Image credit: Hey Paul Studios

doi:10.7244/cmj.2013.07.002
Christine Ma

Three hundred and fourteen patients >40 years old with >20 pack year history and diagnosed acute exacerbation of COPD in hospital were randomised to have either 5 or 14 days of systemic glucocorticoids. The primary end point of this study was the time to next exacerbation over a follow-up period of 6 months, and secondary end points examined all-cause mortality, changes in pulmonary function testing, clinical performance, glucocorticoid-associated adverse events. Apart from a higher cumulative glucocorticoid exposure in the 14 day therapy group, there were no statistical differences in primary or secondary outcome measures between the two groups.

'To Give or Not to Give'

Image credit: scribbletaylor

doi:10.7244/cmj.2013.07.001
Shannon Leckey, Thomas Lemon

In order to be passed, the draft bill must first be introduced into the assembly, go through all 4 stages of scrutiny and then be presented for Royal Assent. Ministers aim for the law to be in place by 2015.As medical students, we should all know about the legal regulations surrounding key aspects of medicine, The Welsh Government published the Draft Human Transplantation Act in June 2012 [1]. It proposes that Welsh residents give presumed consent for organ donation unless they ‘opt out’ of the system

CABG superior to PCI for diabetic patients with multi-vessel CAD

Image credit: Charlie J

doi:10.7244/cmj.2013.06.001
Clement Loh Chee Hoou

Coronary artery disease (CAD) affects millions worldwide. In North America, nearly 700,000 people are diagnosed with multi-vessel CAD and require immediate revascularisation and of these, 200,000 are diabetic. Coronary artery bypass graft (CABG) surgery or percutaneous coronary intervention (PCI) are the two main modalities of revascularisation. The previous BARI, CARDia, TAXUS and SYNTAX randomised clinical trials offered conclusive evidence favouring CABG over PCI as the preferred method of revascularisation (1).

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