This week in the BMJ
Volume 331, Number 7523, Issue of 29 Oct 2005Misdiagnosing "hysteria" has remained steady since the 1970s
Misdiagnosing "hysteria" has remained steady since the 1970s
Misdiagnosing symptoms of non-psychiatric diseases such as stroke as psychiatric illness ("hysteria") happened in about a third of patients diagnosed with "conversion symptoms" in the 1950s but had fallen to 4% by the 1970s and has remained steady since then. In a systematic review Stone and colleagues (p 989) included almost 1500 adults with motor and sensory symptoms unexplained by disease from 27 studies on diagnostic outcomes with a median follow-up time of five years. Misdiagnosis was most common in patients with gait or movement disorders and a psychiatric history, and the advent of computed tomography did not further improve diagnostic accuracy.
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MRSA infection in a vicious circle with hospitalisation
About a quarter of UK hospital patients with methicillin resistant Staphylococcus aureus (MRSA) bacteraemia are infected before coming to hospital, and nine out of 10 of these patients had been hospitalised before. Wyllie and colleagues (p 992) analysed MRSA infection rates in two hospitals in Oxfordshire over seven years. Half of the patients who came into the hospital infected had no record of previous isolation of MRSA; about a third were admitted to renal, oncology, or haematology wards for intensive day case therapy, and most of the rest were admitted to emergency services.
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Targets for trusts' MRSA infection rates need clarifying
The UK government has set targets for reducing the rates of MRSA infection in hospitals, but it is unclear how these targets translate into tracking the performance of individual trusts. On page 1013 Spiegelhalter discusses how effects of chance variability, regression to the mean, and low power to detect genuine changes may hamper efforts to measure the change in rates. He proposes several ways for improving the assessment of performance.
Salivary nicotine test increases cessation rates
Incorporating a 10 minute point of care test for salivary nicotine metabolites into a general dental practice's smoking cessation programme can increase two month cessation rates by almost a fifth. In a randomised controlled trial of 100 smoking adults, Barnfather and colleagues (p 999) found that adding the immediate visual and personalised biofeedback to usual care also decreased overall tobacco use. Mean nicotine metabolite values at two months were 2.58 for cases and 4.29 for controls. The intervention reinforced counselling and provided a more supportive environment for potential quitters, say the authors.
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Community based learning produces better doctors
Young doctors who graduated from a medical school with community oriented, problem based learning performed better than graduates of traditional medical schools. A historical cohort comparison study by Tamblyn and colleagues (p 1002) compared performance in the first few years of practice of graduates of Sherbrooke University in Quebec, Canada, before and after its curriculum reforms, and with three traditional medical schools in the region as additional controls. Those who graduated after the introduction of problem based learning prescribed more mammography screening and disease specific drugs (as opposed to symptomatic prescribing) and provided better continuity of care. There was no difference in prescribing rates for contraindicated drugs.
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