¿Qué podemos aprender de los errores en el abordaje de la crisis opioides en Estados Unidos? / What can we learn from the errors in management of opioids epidemy in United States of America

La epidemia de opioides declarada en Estados unidos ha suscitado una profunda preocupación y polémica en torno al uso de estos fármacos. Aunque este problema no se ha extendido a Europa hasta el momento, se considera importante estudiar cuáles han podido ser los errores que se han cometido en Estados Unidos en el abordaje de esta epidemia. En este trabajo se identificaron cuatro errores respecto a las premisas adoptadas por los Estados Unidos para establecer la estrategia de lucha contra la epidemia: falta de adecuada identificación de las causas y el origen de la epidemia, error en la identificación de culpables, la mezcla de datos correspondientes a opioides de prescripción con los de opioides ilegales y una incorrecta cuantificación del problema. Como consecuencia de estos errores las soluciones y medidas aplicadas fueron ineficaces, tardías y estuvieron dirigidas a unos objetivos incorrectos. (AU)

The opioids epidemic declared in the United States of America has generated a deep preoccupation and controversy in relation to the use of these drugs. Although this problem has not been extended to Europe until today, it seems relevant to analyze the errors that have been made by United States. In this article we have identified four errors related to the premises adopted by this country in the design of the strategy to fight the epidemic: inadequate identification of causes and origin of the epidemic, error in the identification of guilty, mixing of data related to prescription opioids and illegal opioids and an incorrect quantification of the problem. As consequence of these errors, the applied solutions and measures were inefficacious, late and were directed towards incorrect targets. (AU)

"To suit the occasion, I wore my schizophrenic fancy dress"1 - the life of Janet Frame.

OBJECTIVE: Janet Frame (1924-2004) was one of New Zealand's most celebrated authors. Much of her work stems from her experiences as a psychiatric patient. She was hospitalised for about eight years with a diagnosis of schizophrenia. Treatments included insulin coma therapy and unmodified electroconvulsive therapy. Her doctors then planned for her to have a leucotomy, which was cancelled upon discovery that one of her works had won a prestigious literary award. She subsequently moved to England and was assessed at the Maudsley Hospital by Sir Aubrey Lewis. She was found to never have suffered from schizophrenia; her condition was instead attributed to the effects of overtreatment and prolonged hospitalisation. She reflected profoundly on these experiences in her writing, and those who are interested in psychiatry are truly fortunate to have access to her autobiographies, fiction and poetry. CONCLUSIONS: Janet Frame has written both autobiographical and fictional accounts of her many years of psychiatric treatment, describing individuals, interpersonal relationships, and everyday life in these institutions. Her own life story demonstrates extraordinary recovery and achievement.

Thomas Mann: Vascular Fatal Illness of the Writer Who Mastered Disease Through Literary Fiction.

Ruptured iliac artery may initially clinically mimic an isolated inferior limb venous involvement. It was indeed an acute iliac artery dissection complicated by contained rupture and misdiagnosed as inferior limb venous thrombosis that led to the death of Thomas Mann in 1955. The details of the complex case are analyzed. Considerations of medical interest and on actuality of his work are also added.

Alcoholismo y degeneración el el manicomio departamental de Antioquía, Colombia (1920-1930) / Alcoholism and degeneration in the departamental mental Hospital of Antioquía, Colombia, 1920-1930

En este artículo se analizan 159 historias clínicas de pacientes con diagnósticos relacionados al consumo de alcohol en el Manicomio Departamental de Antioquia entre 1920 y 1930. En esa década se inició una transformación institucional con la llegada a la dirección del Dr. Lázaro Uribe Calad. Además fue muy discutido entre médicos y políticos el lugar del alcoholismo como causa determinante de la degeneración racial. En los escritos médicos se evidencia una preocupación constante debido a las terribles consecuencias que podía traer el elevado consumo de alcohol en la sociedad. Sin embargo, en la revisión exhaustiva de fuentes como las estadísticas anuales del Manicomio y las historias clínicas, encontramos que la práctica clínica refleja otra realidad. Se concluye que la cantidad de pacientes que fueron diagnosticados como alcohólicos o cuya etiología estuvo vinculada con la bebida, fueron muy inferiores a los señalados por los médicos. Dichos ingresos respondieron principalmente a problemas de orden moral y social, mas no a cuestiones propiamente psiquiátricas (AU)

In this article we analyze 159 clinical records of patients with diagnoses related to alcohol at the Departamental Mental Hospital of Antioquia, between the years of 1920 and 1930. In that decade an institutional transformation began with the arrival at the direction of Dr. Lázaro Uribe Calad. Besides it was very discussed in the medical and political sector the idea of the racial degeneracy, a matter in which alcoholism played a central role. It is observed in medical publications a constant concern due to the terrible consequences that the high consumption of alcohol could bring in society. However, a deeper review of sources such as the annual Statistics of the Mental Hospital and the clinical records, shows how clinical practice reflected another reality. It is concluded that both, the number of patients who were diagnosed as alcoholic or whose etiology was related to the drink, were much lower than those indicated by the doctors. These incomes mainly responded to moral and social problems, but not to psychiatric issues (AU)

Cajal's unbearable cephalalgias: The consequences of a misdiagnosis.

Around the age of 66 Cajal consulted neurologist Nicolas Achúcarro complaining of "unbearable cephalalgias". He had not ever suffered from headaches. The diagnosis of early arteriosclerosis that was considered at the time a physiological, irreversible ailment of ageing had a strong emotional impact on Cajal. Comorbid depression, insomnia and self-treatment with escalating doses of Veronal® (barbital), a short-acting barbiturate, presumably aggravated the situation. Exposure to warm environments and being involved in tense discussions were identified as triggering factors of the headaches. Achúcarro and Cajal were probably assuming scientific concepts at the time, such as cerebral congestion, increased temperature at the cerebral cortex during mental activity and vasoconstriction and vasodilatation phenomena. Up to his death aged 82, no evidence was discovered of any organic nervous system disorder. Cajal remained anxious up to the end of his life fearing an impending cerebral haemorrhage. The diagnosis was followed by profound lifestyle changes such as social isolation, which forced him to leave his laboratory. Cajal's cephalalgias marked in some way the end of the Spanish school of neurohistology.

A Re-Examination of the History of Etiologic Confusion between Dengue and Chikungunya.

Contrary to the perception of many researchers that the recent invasion of chikungunya (CHIK) in the Western Hemisphere marked the first episode in history, a recent publication reminded them that CHIK had prevailed in the West Indies and southern regions of the United States from 1827-1828 under the guise of "dengue" (DEN), and that many old outbreaks of so-called "dengue" actually represented the CHIK cases erroneously identified as "dengue." In hindsight, this confusion was unavoidable, given that the syndromes of the two diseases-transmitted by the same mosquito vector in urban areas-are very similar, and that specific laboratory-based diagnostic techniques for these diseases did not exist prior to 1940. While past reviewers reclassified problematic "dengue" outbreaks as CHIK, primarily based on manifestation of arthralgia as a marker of CHIK, they neither identified the root cause of the alleged misdiagnosis nor did they elaborate on the negative consequences derived from it. This article presents a reconstructed history of the genesis of the clinical definition of dengue by emphasizing problems with the definition, subsequent confusion with CHIK, and the ways in which physicians dealt with the variation in dengue-like ("dengue") syndromes. Then, the article identifies in those records several factors complicating reclassification, based on current practice and standards. These factors include terms used for characterizing joint problems, style of documenting outbreak data, frequency of manifestation of arthralgia, possible involvement of more than one agent, and occurrence of the principal vector. The analysis of those factors reveals that while some of the old "dengue" outbreaks, including the 1827-1828 outbreaks in the Americas, are compatible with CHIK, similar reclassification of other "dengue" outbreaks to CHIK is difficult because of a combination of the absence of pathognomonic syndrome in these diseases and conflicting background information.

Medicine, art and the death of Franz Liszt.

Much might be learned about the art of medicine by studying the lives of great artists. The year 2011 marked the bicentenary of the birth of Franz Liszt (1811-1886), one of the most accomplished musicians of the 19th century. Lessons relevant to contemporary medical practice can be found by examining aspects of his life and art, as well as the failure of his physicians to practise their own art during his final days.

Breast cancer screening: a 35-year perspective.

Screening for breast cancer has been evaluated by 9 randomized trials over 5 decades and recommended by major guideline groups for more than 3 decades. Successes and lessons for cancer screening from this history include development of scientific methods to evaluate screening, by the Canadian Task Force on the Periodic Health Examination and the U.S. Preventive Services Task Force; the importance of randomized trials in the past, and the increasing need to develop new methods to evaluate cancer screening in the future; the challenge of assessing new technologies that are replacing originally evaluated screening tests; the need to measure false-positive screening test results and the difficulty in reducing their frequency; the unexpected emergence of overdiagnosis due to cancer screening; the difficulty in stratifying individuals according to breast cancer risk; women's fear of breast cancer and the public outrage over changing guidelines for breast cancer screening; the need for population scientists to better communicate with the public if evidence-based recommendations are to be heeded by clinicians, patients, and insurers; new developments in the primary prevention of cancers; and the interaction between improved treatment and screening, which, over time, and together with primary prevention, may decrease the need for cancer screening.

Unique challenges faced by pediatric neurosurgeon Harvey Cushing in 1909 at Johns Hopkins: a choroid plexus tumor of the lateral ventricle mimicking a cerebellar lesion.

INTRODUCTION: At the turn of the twentieth century, diagnosis of pediatric intracranial lesions frequently relied exclusively on the subtle, nonspecific signs associated with these pathologies. In absence of detailed neuroimaging, erroneous diagnoses and misdirected operative explorations were common within pediatric populations. METHODS: Following institutional review board approval, and through the courtesy of the Alan Mason Chesney Archives, we reviewed the surgical files from the Johns Hopkins Hospital for the years 1896-1912. Harvey Cushing's neurosurgical cases were collected and further analyzed. RESULTS: A 9-year-old boy presented with a year-long history of headaches and blindness. His neurological examination was remarkable for focal cranial nerve deficits and cerebellar signs. Cushing diagnosed a cerebellar tumor with hydrocephalus and performed two suboccipital explorations with negative results. The patient died prior to further operative intervention, and the postmortem examination revealed a large choroid plexus tumor within the left lateral ventricle. CONCLUSIONS: Early neurosurgical diagnosis and operative planning was fraught with difficulties, and surgeons relied solely on history and physical examination for localization of intracranial lesions. Here we report a case of a choroid plexus tumor of the lateral ventricle, which was misdiagnosed by Cushing. This case serves to emphasize the unique challenges faced by pediatric neurosurgeons at the turn of the twentieth century, who relied solely on history and examination to localize intracranial lesions.

Errors and difficulties in the diagnosis of bladder cancer in the 19th century: about an uncommon case reported by Professor Claude-François Lallemand (1790-1854).

Before the official foundation of the specialty of urology in 1870 from Félix Guyon, its exercise was in the hands of general surgeons. One of the most distinguished surgeons interested in urology was Claude-François Lallemand, Professor of Surgery in Montpellier. Despite his enormous experience in the diagnosis and treatment of urinary tract diseases as well as the invention of various surgical instruments for the lower urinary system, Lallemand, however, did not avoid serious diagnostic errors because of the lack of diagnostic tools. Characteristically in the present article we present a serious diagnostic mistake in a patient with bladder cancer with fatal outcome.