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Myotoxicity is a well known side-effect of on medical errors:3 while the public views open statins, with a reported incidence of 1–7%.3 No reporting as a very effective way of reducing errors, cases of rhabdomyolysis due to monotherapy physicians prefer confidentiality. We conducted a with ezetimibe have been described. However, survey to evaluate the potential contribution of a disclosure policy to hospital image. Our findings taking statins has been documented in two shed additional light on the discordance of opinions patients.4 Although MD is a known cause of rhabdomyolysis, the present case strongly suggests that myotoxicity may be elicited by ezetimibe, Russian and Arabic) of a representative sample and poses the question of whether ezetimibe may of the Israeli public (n ¼ 570) using random-dial trigger muscular damage by mechanisms that are software. Respondents were asked to predict the effects of a transparency policy upon public imageof hospitals and doctors, and also to what extent Hospital Clinico Universitario ‘‘Lozana Blesa’’ In addition, we conducted 115 face-to-face interviews of physicians with questions similar to those of the public survey, in three majorteaching hospitals (two from Israel, one from the US). They included 53 residents, 54 attending Hospital Universitario ‘Miguel Servet’ physicians (from internal medicine, surgery and gynecology), six department heads and two hospital The majority of the public indicated that an open disclosure policy would enhance the image of hospitals (Figure 1). By contrast, a majority of Hospital Universitario ‘12 de Octubre’ physicians predicted that disclosing mistakes would damage the image of the hospital (p50.001 vs.
the public). American and Israeli physicians had Since Israel has a markedly heterogeneous population, we examined whether ethnic or socialgroups might have different answers. In all sub- 1. Lebo RV, Gorin F, Fletterick RJ, Kao FT, Cheung MC, groups, including Russians, Arabs, and people with Bruce BD, et al. High-resolution chromosome sorting low or high levels of education, the majority and DNA spot-blot analysis assign McArdle’s syndrome inchromosome 11. Science 1984; 225:57–9.
consistently responded that transparency wouldbenefit hospital image.
2. Bays HE, Moore PB, Drehobl MA, Rosenblatt S, Coth PD, Dujovne CA, et al. Effectiveness and tolerability of ezetimibe Both the public and physicians thought that in patients with primary hypercholesterolemia: pooled analysis disclosure to patients of individual mistakes by of two phase studies. Clin Ther 2001; 23:1209–30.
3. Evans M, Rees A. The myotoxicity of statins. Curr Opin Lipidol 4. Fux R, Mo¨rike K, Gundel UF, Hartmann R, Gleiter CH.
Ezetimibe and statin associated myopathy. Ann Intern Med2004; 40:671–2.
Discordant public and professionalperceptions on transparency inhealthcare Sir,Transparency is becoming a major issue in health-care.1,2 Recent work shows substantial differences Figure 1. Effect of a disclosure policy upon hospital between views of physicians and those of the public image, as perceived by the public and by physicians.
doctors would enhance the doctor’s image. The 5. Australian Council for Safety and Quality in Health Care public thought that in fact, few or none of the and Standards Australia International. Open DisclosureStandard: A National Standard for Open Communication in doctors disclose errors, whereas both Israeli and Public and Private Hospitals, Following An Adverse Event in American physicians felt disclosure was common Health Care. [ (p50.001). The public and the physicians agreed docs/ACSQHC_Open_Disclosure_Standard.pdf].
that publication of performance data would improve Our survey suggests that while physicians from both sides of the Atlantic Ocean share scepticismabout the value of transparency, people from very diverse backgrounds share convictions regarding its importance. As discordance between publicand doctors seems to cross cultures, bridging over mistrust appears to be a global challenge.
Hyponatraemia following traumatic brain injury It seems that both the public and physicians know (TBI) is a common complication, occurring in 13% physicians make mistakes, but physicians may of cases.1 The commonest cause of hyponatraemia not yet fully appreciate the extent of this public is the syndrome of inappropriate antidiuretic hor- mone secretion (SIADH), which is responsible for Transparency in itself appears to become, in public over 90% of cases,1 whereas cerebral salt wasting, eyes, an indicator of quality. ’Tell the truth and tell medications and injudicious use of intravenous it fast’4 should become standard in healthcare, fluids may also cause hyponatraemia following TBI.
as recently adopted in Australia,5 but this cultural As glucocorticoid deficiency can present with shift may be a tough professional challenge.
hyponatraemia similar to that found in SIADH, it This work was presented at the annual meeting is essential to exclude adrenal insufficiency before of the American Public Health Association in making a diagnosis of SIADH.2 This may be of particular importance in the case of TBI, as recent data have indicated a high frequency of undiag- nosed hypopituitarism among long-term survivors.3 In addition, 16% of acute head injury patientsshow biochemical evidence of adrenocorticotrophin (ACTH) deficiency.4 Acute hypopituitarism with ACTH deficiency may therefore be a potentially important, cause of hyponatraemia in patients with acute TBI, which is misdiagnosed as SIADH.
To illustrate this potential pitfall in diagnosing recent experience of three cases where acute TBI was complicated by hyponatraemia of between 125–130 mmol/l (normal 135–145 mmol/l) with all the biochemical features of SIADH (clinical euvolaemia, inappropriately concentrated urine and a natriuresis).2 All three patients had significanthead trauma. Patient A had a penetrating skullinjury after falling from a ladder (Figure 1), patient B had diffuse axonal injury after a road traffic accident 1. Smith R. Transparency: a modern essential. Br Med J 2004; and patient C had intracerebral haematoma fol- lowing a fall. At presentation, patients A and 2. Mazor KM, Simon SR, Yood RA, et al. Health Plan Members’ B were also hypotensive (blood pressures of 80/30 Views about Disclosure of Medical Errors. Ann Intern Med and 70/40 mmHg, respectively) and hypoglycaemic (plasma glucoses of 0.9 and 2.5 mmol/l, respec- 3. Blendon RJ, DesRoches CM, Brodie M, et al. Views tively) and required vasopressor support and of Practicing Physicians and the Public on Medical Errors.
continuous intravenous dextrose infusion. Patient C had normal blood pressure and plasma glucose.
4. Augustine N. Managing the crisis you tried to prevent.
The diagnosis of post-traumatic hypopituitarism Harvard business review on crisis management. The Harvardbusiness review paperback series. Boston, Harvard Business with ACTH deficiency was suspected in cases


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