Fat Dogs, Rubber Dolls, & Surgeon's Birthdays: BMJ Xmas Special

Peter Russell

December 11, 2020

Original research, light-hearted features, and quirky comment articles are contained in the latest Christmas issue of The British Medical Journal.

No Cause for Birthday Celebrations?

Patients might be well advised to avoid a trip to the operating theatre on their surgeon's birthday.

A study found going under the knife on their surgeon's birthday carried a higher risk of mortality than on other days of the year.

Researchers implied that rushing procedures ahead of birthday celebrations should be added to a list of other distractions, such as noise, equipment problems, and personal conversations that could have a detrimental effect on the performance of medical professionals.

The study used US Medicare data of patients aged 65 to 99 who underwent one of 17 common emergency surgical procedures at US hospitals in 2011 to 2014.

Mortality rates after 30 days for patients who underwent procedures on a surgeon's birthday were 7.0% compared with 5.6% on other days.

The authors said that despite the limitations of their observational study, the increased mortality might be associated with distraction related to rushing surgery ahead of later celebrations, birthday conversations with team members, or even receiving birthday text messages.

"It may be possible that the patterns we observed extend to other distracting life events," they concluded.

If Music Be the Balm of Pain

Post-operative pain and the need for pain relieving drugs after surgery could be reduced if patients are played soothing words and music during surgery, researchers suggested.

The study was based on 385 patients aged 18 to 70 who underwent procedures under general anaesthesia lasting 1 to 3 hours in five tertiary care hospitals in Germany.

Half of the patients assigned randomly to a control group were played silence through earphones. The other half were played music or spoken positive suggestions based on hypnotic techniques for 20 minutes in each half hour of their surgery.

The study found that while pre-surgery pain levels were similar between all the participants, during the first 24 hours after surgery, pain scores were consistently and significantly lower in the intervention group, with an average reduction of 25%.

The number of patients who required any opioid after surgery was also reduced in the intervention group: 121 of 191 (63%) patients in the intervention group versus 155 of 194 (80%) in the control group – a reduction of 16%.

No adverse events were recorded, the researchers said.

"Therapeutic suggestions during surgery could provide a safe, feasible, inexpensive, and non-drug technique to reduce postoperative pain and opioid use, with the potential for more general use," they said.

The authors said their findings suggested that surgical teams should be mindful of the effects of background noise or 'negative conversations' during surgery.

They said that despite the effects of general anaesthesia, research had observed "higher frequencies of wakefulness without explicit memory have been observed in patients during surgery as well as reactions to meaningful events such as a simulated complication during surgery".

In a linked editorial, Canadian researchers said the findings added to other studies suggesting that the subconscious might be an important target for improving patient experience and outcomes.

Further investigation was needed though in what could turn out to be "an important line of inquiry that may change future practice".

They caution that care would be needed to ensure that any words played to patients who speak different languages did not have unintended, negative effects.

Pooch Potatoes?

A dog with diabetes could act as a warning that their owner has a higher risk of developing type 2 diabetes, a study found.

Researchers said the findings supported the view that dog owners and their pets might share some lifestyle behaviours, such as levels of physical activity.

Cross sectional studies have suggested a link between adiposity in dog owners and their pets. However, no previous research has investigated whether dog and cat owners share a risk of diabetes with their animals.

Researchers in Sweden and the UK used data from a major Swedish pet insurance company involving 132,783 dogs and 84,143 cats between 2004 and 2006.

The information was linked to Swedish health records to identify cases of type 2 diabetes among pet owners.

Owning a dog with diabetes was associated with a 38% increased risk of developing type 2 diabetes compared with owners of dogs who did not have diabetes.

The risk level remained stable when socioeconomic and personal circumstances were taken into consideration.

The study also found the extra risk applied to dogs as well as owners. For instance, the risk of developing diabetes was 28% higher in dogs whose owners had been diagnosed with type 2 diabetes. This estimate, however, was reduced after adjusting for age of the owner.

No association was found between type 2 diabetes in cat owners and diabetes in their cats.

The authors point out that their observational study was limited to individuals who could afford pet insurance and who received drugs to treat their diabetes. However, they conclude: "It is possible that dogs with diabetes could serve as a sentinel for shared diabetogenic health behaviours and environmental exposures."

The 'Eerie' Face of CPR

Liverpool academics recount the intriguing story that links the death mask of a young woman plucked from the river Seine in Paris in the late 19th century to the image recreated for a mannequin used to teach cardiopulmonary resuscitation (CPR) from the 1960s.

Suspecting death by suicide, the pathologist who performed an autopsy on the body was so captivated by the appearance of the girl – thought to be aged around 16 – that he had a plaster death mask made of her face.

During the last decade of the century, replicas were popular throughout bohemian Paris.

She became known as 'L'Inconnue de la Seine' (Unknown Woman of Seine). She was also referred to as the Mona Lisa of Seine because of her eerie smile that made people wonder about her life story and what could have led her to her watery fate.

In 1956, Austrian anaesthetist Peter Safar and US physician James Elam met at the American Society of Anaesthesiologists meeting in Kansas City. Their connection led to the discovery that mouth-to-mouth breathing could maintain blood oxygen levels in people who had ceased breathing. The technique of CPR followed.

When a member of the American Heart Association's CPR committee, recognised that students practising CPR on one another risked causing rib fractures and pain, he approached toy and doll manufacturer Åsmund Laerdal to develop a mannequin for CPR practise.

The project had personal significance for Laerdal, who had once saved his own son from drowning by clearing water from his lungs.

Laerdal recalled a reproduction mask of L'Inconnue on the wall of his grandparents' house and decided to base his doll on that face. He also thought that a female doll would be less intimidating for students learning CPR techniques.

He produced a line of mannequins, one of which, became known as 'Resusci Annie'.

Over the next 60 years, popularity of the mannequin among students of the technique, earnt her the title, 'the most kissed face' of all time.

The identity of the original teenager, whose appearance spawned the mannequin, has never been solved.

The authors of the feature from Liverpool University, say one recent theory is that she was an identical twin from Liverpool who eloped to France with a wealthy suitor, never to be seen by her family again. In a twist to the tale, her twin sister later visited Paris where she was shocked to see a mask of the deceased that resembled a reflection of herself.

Resusci Annie may have helped more than 500 million people train in CPR, saving around 2.5 million lives, the authors say.

However, a linked editorial discussing the ethical questions raised by historical events, asks whether L'Inconnue de la Seine was "morally wronged".

Julian Sheather, a writer and ethicist, says: "Should we be concerned about this circulation of her image without anything resembling consent?"

Road Dahl's 'Dangerous' Medicine

COVID-19 lockdown has led to many children being let loose in the kitchen as hard-pressed parents try to find time to occupy bored offspring.

However, UK researchers have produced a cautionary tale about the possible dangers to health from budding scientists indulging their imagination too far.

Children's author Roald Dahl has proved enduringly popular since his death in 1990. His books, including Charlie and the Chocolate Factory, James and the Giant Peach, and Fantastic Mr Fox have led him to be placed 16th on a list of the 50 greatest British writers since 1945, according to The Times newspaper.

One novel though in particular caught the eye of researchers from the Royal Derby Hospital and Nottingham School of Medicine.

In Dahl's George's Marvellous Medicine, first published in 1981, 8-year-old George Kranky decides to punish his bossy grandmother by replacing her medicine with a concoction of his own.

Mischievous George employed 34 household ingredients including toothpaste, lipstick, shoe polish, washing powder, hot chilli sauce, engine oil, antifreeze, and brown paint.

In the book, grandmother is said to have grown as tall as a house and to have burst through the roof after being duped into taking the potion.

After reading Dahl's book, the researchers and their five children used the National Poisons Information Service database to examine the effects of the ingredients.

The most common toxic effects were:

  • Nausea and vomiting (16 ingredients, 47%)

  • Potentially life-threatening effects (13 ingredients, 38%)

  • Diarrhoea (11 ingredients, 32%)

  • Cardiac problems (6 ingredients, 18%)

The authors acknowledge that they did not combine the potion as described in the book so are unable to comment on the effect that chemical interactions might have had. Nor did they know the dosage that the grandmother was described as taking.

They write: "It is unlikely that children will recreate each step in the making of a marvellous-type medicine, but it is worth being cautious as some of the household ingredients used by George are considerably dangerous and commonly cause severe morbidity in children."

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