Letter to the Editor

Whilst the article by Nicholson AN [1] comprehensively reviews medical and environmental stresses associated with commercial flight, recent widespread increase in press coverage and community perceptions regarding compromised flight safety and security require emphasis. Adverse psychological sequelae resulting from terrorist threat to passenger aircraft leads to avoidance of commercial flights [2] as well as stress and anxiety in flight [3]. There is now community-wide anxiety about flight security in view of recent terrorist attacks such as commercial jets being flown into The Twin Towers in New York City on September 11th 2001 [2] and more recent security fears on trans-Atlantic flights [4]. Psychological stresses associated with increased pre-departure security checks and flights delayed or cancelled by security concerns have increased since September 11th [3]. Libyan involvement in the 1988 mid-air bomb explosion of a Pan-Am flight over Lockerbie was widely speculated at the time and further highlighted in 2001 [5]. Air-rage (passengers being verbally or physically aggressive or disruptive during flight) related to substance and alcohol use/refusal is increasing, poses physical and psychological risks to others on the plane and occasionally requires costly and inconvenient diversion of the flight [6]. Passengers with flight anxiety who already have fears out of proportion to the excellent safety of commercial flight pre-September 11th [7] will now have to contend with random unpredictable acts of violence and terrorism. Fear of flying possesses significant public health implications [7], affecting 10-40% of adult passengers [8] and up to 9.2% of crew staff [9]. In extreme cases it leads to severe anxiety reactions including panic attacks in-flight [3]. On the ground, avoiding flights exposes individuals to risks associated with using alternative transport [7]

A shift from passive teaching at medical conferences to more interactive methods improves physician learning

Conferences that deliver interactive sessions designed to enhance physician participation, such as role play, small discussion groups, workshops, hands-on training, problem- or case-based learning and individualised training sessions, are effective for physician education

Hyperosmolar Diabetic Non-Ketotic Coma, Hyperkalaemia and an Unusual Near Death Experience

Generally, cardiac arrest due to pulseless electrical activity has a poor outcome, except when reversible factors such as acute hyperkalaemia are identified and managed early. Hyperosmolar diabetic non-ketotic coma may lead to acute hyperkalaemia. Hyperosmolar diabetic non-ketotic coma is a metabolic emergency usually seen in elderly non-insulin dependent diabetics, characterized by severe hyperglycaemia, volume depletion, altered consciousness, confusion and less frequently neurological deficit. Cerebrovascular accident or transient ischaemic attack may be mistakenly diagnosed, particularly if the patient has no history of diabetes mellitus. Delays in diagnosis and management of glycaemic emergencies presenting as a constellation of neurological abnormalities can be avoided by routine early measurement of blood glucose. Hyperosmolar diabetic non-ketotic coma should be considered in any patient with altered consciousness or neurologic deficit in conjunction with hyperglycaemia. As hyperosmolar diabetic non-ketotic coma results in severe fluid depletion, electrolyte disturbance, profound hyperglycaemia and an altered mental state, the guiding principles of therapy include aggressive rehydration, insulin therapy, correction of electrolyte abnormalities and treatment of any underlying illnesses. Treatment of acute hyperkalaemia includes calcium ions, insulin with dextrose, salbutamol and haemodialysis

Ciguatera Poisoning: A Global Issue with Common Management Problems

Ciguatera poisoning, a toxinological syndrome comprising an enigmatic mixture of gastrointestinal, neurocutaneous and constitutional symptoms, is a common food-borne illness related to contaminated fish consumption. As many as 50 000 cases worldwide are reported annually, and the condition is endemic in tropical and subtropical regions of the Pacific Basin, Indian Ocean and Caribbean. Isolated outbreaks occur sporadically but with increasing frequency in temperate areas such as Europe and North America. Increase in travel between temperate countries and endemic areas and importation of susceptible fish has led to its encroachment into regions of the world where ciguatera has previously been rarely encountered. In the developed world, ciguatera poses a public health threat due to delayed or missed diagnosis. Ciguatera is frequently encountered in Australia. Sporadic cases are often misdiagnosed or not medically attended to, leading to persistent or recurrent debilitating symptoms lasting months to years. Without treatment, distinctive neurologic symptoms persist, occasionally being mistaken for multiple sclerosis. Constitutional symptoms may be misdiagnosed as chronic fatigue syndrome. A common source outbreak is easier to recognize and therefore notify to public health organizations. We present a case series of four adult tourists who developed ciguatera poisoning after consuming contaminated fish in Vanuatu. All responded well to intravenous mannitol. This is in contrast to a fifth patient who developed symptoms suggestive of ciguatoxicity in the same week as the index cases but actually had staphyloccoccal endocarditis with bacteraemia. In addition to a lack of response to mannitol, clinical and laboratory indices of sepsis were present in this patient. Apart from ciguatera, acute gastroenteritis followed by neurological symptoms may be due to paralytic or neurotoxic shellfish poisoning, scombroid and pufferfish toxicity, botulism, enterovirus 71, toxidromes and bacteraemia. Clinical aspects of ciguatera toxicity, its pathophysiology, diagnostic difficulties and epidemiology are discussed

Representation of authors and editors from poor countries: Quality medical research from poor countries could be privileged in high impact journals

In highlighting the marked under-representation of authors and editors from countries with low human development indexes in prestigious tropical medicine journals 1, the paradox of the greater burden of tropical disease afflicting people living in the under-developed world being studied, then published, by researchers in countries with a high development index is clearly demonstrated. Significant obstacles confront researchers who live and work in resource-poor but disease-prevalent countries in conducting and publishing medical research into diseases of poverty 2. These inequities are exacerbated by poor dissemination of, and reduced access to, quality medical research 3 amongst clinicians in countries where these diseases are endemic. This may be ameliorated by allowing duplicate publication within local journals 4 or forums of difficult to access articles from prestigious journals with high local relevance, for a lesser cost or for free. Journal space in high impact journals could be quarantined for articles on locally relevant medical research conducted by researchers from less developed countries. Publications could be actively solicited or commissioned from researchers who live and work in these countries in special focus issues. Although quality clinical research flow from research-rich to research-poor countries is limited 5, the reverse also occurs. Awareness of health issues pertaining to less developed countries amongst clinicians in the developed world could be improved by increased presence of article summaries and links to publications of note originating from less developed countries within sections such as Journal Watch

Letter To The Editor, British Medical Journal

Medication dosing and administration errors occur relatively frequently during paediatric resuscitation even when led by highly trained and/or senior clinicians in tertiary paediatric emergency medicine centres. The level of care in mixed Emergency Departments is likely to improve with increased uptake by health care workers looking after children of paediatric life support courses, although skills and knowledge maintenance may degrade over time

Medical Response to Terrorism: Preparedness and Clinical Practice (Book Review)

Book Review of Medical Response to Terrorism: Preparedness and Clinical Practice, Keyes DC, Burstein JL, Schwartz RB and Swienton RE, Lippincott Williams & Wilkins, 2005, ISBN 0781749867

Acute severe non-traumatic muscle injury following reperfusion surgery for acute aortic occlusion: case report

Acute aortic occlusion is a rare but catastrophic disease with a high mortality rate. Severe perioperative complications could result from revascularization of infarcted muscles. Muscle cell ischaemia and massive volume cell death lead to the release of myoglobin, potassium, and lactic acid, which could be fatal if not recognised or treated early. We highlight the life-threatening adverse effects resulting from bulk tissue infarction from non-traumatic causes such as aortic occlusion followed by the metabolic sequelae of reperfusion. This is similar to the pathophysiology of traumatic crush injuries and rhabdomyolysis. The case highlights the vigorous pre-emptive treatment of acidosis and hyperkalaemia required during surgical revascularisation to potentially avert adverse surgical outcomes in acute aortic obstruction