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10-MINUTE CONSULTATION

Tooth avulsionIsabelle Moran,1 Martin James,1 William Cook,2 Michael Perry1

WHAT YOU NEED TO KNOW

•  Do not attempt to reimplant an avulsed primary (baby) tooth

•  Re-implantation of adult tooth within an hour of the injury improves outcomes

•  Milk is an ideal storage medium

1Oral and Maxillofacial Surgery, Northwick Park Hospital, London HA1 3UJ, UK2Emergency Medicine, Northwick Park HospitalCorrespondence to: I Moran isabellemoran@nhs.netThis is part of a series of occasional articles on common problems in primary care. The BMJ welcomes contributions from GPs.

A 7 year old boy has tripped in the playground and knocked his front tooth out. He attends the emergency department with his mother, who has the tooth in her hand. He is stable and has no other injuries of concern.

What you should coverPermanent dental problems can be avoided by taking a simple dental history and doing a basic examination. The main question is whether re-implantation of the tooth is appropriate. Was this a primary (baby) tooth or a permanent (adult) tooth? At 6-8 years of age, the primary central incisors have usually fallen out and the larger, permanent incisors have erupted (fig 1). The potential risks associated with avulsion injury of a primary tooth, such as disturbances in eruption and appearance of the developing permanent teeth, can be increased if a primary tooth is re-implanted.1 This is not advised, and monitoring of permanent tooth eruption is essential following injury.2 3

History•  Establish whether the adult with the child has legal

responsibility.•  Determine what happened, including the mechanism

of the injury and details such as the height of the fall and the surface on to which the patient fell. This can indicate associated injuries (eg, facial fractures, head injury).

•  Note the time of injury. Re-implantation within one hour is associated with improved survival of the tooth.2 3 Delayed re-implantation is still advised but has a less good prognosis (table).

Primaryincisor

Permanentincisor

Fig 1 |  Diagram highlighting difference in size between primary and permanent incisors. The primary central incisor is approximately 16 mm in length, two thirds the size of its permanent successor

Outcome of tooth avulsion3

Treatment at time of injury Chance of tooth loss at 3 years (%)Immediately re-implanted 0Transported in appropriate medium before re-implantation

11

Kept dry for >1 hour 58

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•  Explore whether (and how) the tooth has been stored. Water and dry environments damage avulsed teeth; milk is ideal.2 3

•  As you consult, be alert to the possibility of non-accidental injury, including delayed presentation and an inconsistent history. Pursue this as necessary.

Examination•  Examine the avulsed tooth:

 – Is it complete or fractured? – Is soft tissue injury evident, possibly indicating impaction of tooth fragments?

 – Are other teeth damaged?•  If no other injuries are suspected, a radiograph of the

socket is not routinely advised.2 3

•  A chest radiograph is indicated when tooth fragments cannot be accounted for.4

•  Examine the tooth socket: has the tooth fractured while the root remains? This does not contraindicate re-implantation.

•  Is the surrounding bone mobile on palpation indicating a fracture?

What you should do•  Manage injuries of greatest concern first.•  Provide analgesia as necessary.•  A tetanus booster is indicated if the tetanus status

of the child is unclear and the tooth has been contaminated.

•  Identify any soft tissue injury. Management can often be postponed until the avulsed tooth has been dealt with.The most commonly avulsed permanent tooth is the

central incisor.2 3 The tooth is attached to the jaw by small root fibres, and its blood supply enters through an opening at the root tip (fig 2). An avulsion injury damages these structures. Re-implantation within an hour of the incident can preserve the vascular supply and surface attachments.2 3 Avulsion of the lateral incisor is also commonly seen (fig 3).

Root

Bloodsupply

Crown

Root �bres

Bone

Gum

Fig 2 |  Anatomy of central incisor (upper front tooth)

Procedure to re-implant a tooth• Administer local anaesthetic to the socket, although this is not essential• Hold the tooth by the crown and gently wash any debris with running saline for 10

seconds• Irrigate the socket with saline• With the convex surface of the tooth facing towards the lips, slowly push the

tooth into the socket. Use the adjacent teeth and the patient’s bite to aid accurate repositioning. If resistance is felt, do not attempt to advance the tooth further.

• Ask the patient to bite gently on gauze to hold the tooth in position• Prescribe a seven day course of amoxicillin3

• Advise the patient to brush twice daily and use chlorhexidine mouth rinse twice daily for one week, eat a soft diet, and arrange a dental visit as soon as possible

• Referral to the maxillofacial team before discharge:– Successful re-implantation—The tooth will need to be splinted to the adjacent teeth through use of a wire– Unsuccessful re-implantation—Store the tooth appropriately and refer promptly

• Re-implantation of a tooth is contraindicated in severe immunosuppression and severe cardiac conditions (for example, with a high risk of endocarditis)1

HOW PATIENTS WERE INVOLVED IN THIS ARTICLEArticle predates our patient partnership changes, and so no patients were involved.

P

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Ideally, dentally qualified professionals should perform re-implantation. However, as delay will significantly reduce the prognosis, any competent person should attempt re-implantation as soon as possible (see box on previous page).

If re-implantation cannot be performed immediately, the tooth must be held by the white crown and placed in an appropriate storage medium to prolong cell survival.5 Cold milk or Hank’s balanced salt solution are preferred mediums; if these are not available, saline can be used as an alternative.5

Considerable damage to the tooth can result in failure of the blood supply to regenerate and replacement of the root surface fibres with bone (ankylosis). Ultimately, these teeth will need root canal treatment and long term follow-up by a dentist.

Differences in treating adolescents and adultsOwing to reduced bone elasticity, adults’ teeth are more likely to fracture than avulse. The management of tooth avulsion remains the same. However, by 10-11 years of age, the blood flow to the incisors is reduced, preventing revascularisation after re-implantation and necessitating root canal treatment.

Tetracycline (narrower spectrum antibiotic) should be prescribed, rather than amoxicillin, for patients aged over 12 years to facilitate the healing of tooth tissues.3

Competing interests: None declared.Cite this as: BMJ 2016;352:i1394Find this at: http://dx.doi.org/10.1136/bmj.i1394

FURTHER CLINICAL GUIDELINESThe Dental Trauma Guide. Evidence based guidance on tooth avulsion. www.dentaltraumaguide.org2

EDUCATION INTO PRACTICE• How might you ensure that all clinical and reception staff

are aware that re-implantation of a tooth within one hour improves outcome?

• Does your department have appropriate storage solutions available?

WHAT YOUR PATIENT IS THINKING

Healthy approaches to rare conditionsWhat do you do if your patient has a condition you’ve never come across before? Polly Moyer offers encouragement for doctors feeling overwhelmed

About one in 17 people will develop a rare condition at some point in their lives, so you’re going to encounter them in your clinics. When diseases are incurable, some doctors may feel defeated by them. There’s no need to be. But it is worth being aware of some potential pitfalls and how to avoid them.

Acknowledge, don’t dismissIn 2006, I was diagnosed with mal de debarquement syndrome (MdDS). I soon came across the first pitfall—people doubting what I say.

MdDS is one of many “invisible” conditions or disabilities and this can cause some health professionals to doubt or dismiss the symptoms, even after diagnosis. This is understandable because we look “normal” (and the ruling-out test results are generally “normal” too), but it can be upsetting for patients. Invisible disabilities can result in stigmatisation, prejudice, and discrimination in our daily lives. If our doctors also don’t acknowledge the symptoms, and the difficulties they cause us, this may feel more shocking than the original diagnosis.

WHAT YOU NEED TO KNOW

•  Patients with “invisible disabilities” can struggle to feel believed by doctors; demonstrating an awareness of this will help reassure your patients

•  Please respect the research patients have done; we are trying to help you to help us

•  Community doctors can help us do the joined-up thinking after referrals to specialists, and their support and encouragement for our hard work in self managing are vital

Fig 3 | Photograph of avulsion injury to upper left lateral incisor

For series information contact Rosamund Snow, patient editor, rsnow@bmj.com

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Respect what we knowI came across the second pitfall when I researched the condition myself. Understandably, some doctors feel frustrated because they simply don’t have time to read up on rare diseases themselves. However, with the rise of patient groups, we may be well connected with other people with the same condition and may know what onward referrals, investigations, and treatments have helped them. We will also understand that what helps one person might not help everyone with the same syndrome.

We don’t want to give up, and we don’t want our doctors to give up either. There has never been a better time to be a doctor of someone with a rare condition. The United Kingdom has an excellent rare diseases strategy, which supports a joined-up approach to these conditions and should drive much needed research. The internet allows patients to connect with relevant clinical researchers, patient groups, and organisations such as Findacure.

Through the patient facing Isabel system many of your patients will be able to self diagnose, which can save a lot of time.

About one in 17 people will develop a rare condition at some point in their lives. When diseases are incurable, some doctors may feel defeated by them

0.5 CREDIT

Your role is so importantFor an example of great practice, I wish you could meet my current GP. Because she knows my sister had similar symptoms she understands my concerns for my niece. She commiserates with me that there are no treatment trials here in the UK. She accepts the MdDS symptom level calibration sheet, even though it was written by patients, not doctors. She is interested to hear about the questions posed by the researchers and the progress they’re making, against the odds. Her approach is to go back through my medical history and try to investigate and then treat the things that rendered me susceptible to MdDS and migraine.

She encourages me to find ways to keep symptom levels as low as possible and celebrates with me when I find something that works. Meanwhile she lets me record our consultations and she never says, “But you look well.”

After all this time, I have a doctor I can trust.Competing interests: I am a cofounder of Action for MdDS UK and have blogged for organisations such as Findacure and Rare Diseases UK.

Cite this as: BMJ 2016;353:i2042Find this at: http://dx.doi.org/10.1136/bmj.i2042

ROSE

LLO

YD

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FROM DRUG AND THERAPEUTICS BULLETIN

The management of dry eyeDrug and Therapeutics Bulletin Editorial Office, London dtbeditor@bmjgroup.com

Dry eye disease (also called keratoconjunctivitis sicca) is a common condition, with a prevalence ranging from 8% to 34%, depending on the criteria used.1 It becomes more common with increasing age and affects more women than men. Artificial tears and ocular lubricants are considered the mainstay of treatment, and there is a very wide range of these products available. In England in 2014, over 6.4 million prescription items for artificial tears, ocular lubricants, and astringents were dispensed in the community at a cost to the NHS of over £27 million.2 In this article we review the management of dry eye disease, focusing on artificial tears and ocular lubricants.

About dry eyeThe tear film, which covers the cornea and exposed conjunctiva, is composed of three layers: a mucin layer that sits on the epithelial surface; a middle aqueous layer; and an outer lipid layer that plays a role in preventing tear evapouration.3 Dry eye has been defined as a multifactorial disease of the tears and ocular surface that results in symptoms of discomfort, visual disturbance, and tear film instability with potential damage to the ocular surface. It is accompanied by increased osmolarity of the tear film and inflammation of the ocular surface.4

There are two main types of dry eye: aqueous insufficiency (due to reduced aqueous secretion from lacrimal glands) and evapourative (due to a deficient lipid layer).

Aqueous insufficiency is divided into two main groups: Sjögren's syndrome-related dry eye and non-Sjögren's syndrome-related dry eye (which includes the use of systemic medication). Dry eye in Sjögren's syndrome (an autoimmune disease) is often severe and requires more aggressive treatment.5

Evapourative dry eye is most commonly a result of meibomian gland dysfunction.4 External causes include allergy, topical medication use (including preservative content), and contact lens wear.

Risk factors associated with dry eye include: female sex; older age; postmenopausal oestrogen therapy; computer

WHAT YOU NEED TO KNOW

•  Identify underlying conditions such as conjunctivitis, blapharitis, Sjőgren’s, and ocular surgery

•  Review medication such as antihistamines, b blockers, oestrogen, and antidepressants

•  In the absence of comparative studies begin with practical measures and low cost preparations of artificial tears and lubricants

use; contact lens wear; a diet low in omega-3 essential fatty acids or a high ratio of omega-6 to omega-3 fatty acids; refractive eye surgery; bone marrow transplantation; hepatitis C; some systemic and ocular medications; and vitamin A deficiency.6 A study of UK women, in whom the prevalence of dry eye disease was 10%, found an association with cataract surgery and also with pain syndromes, raising the possibility that altered pain perception and psychological and somatisation factors have an influence on dry eye disease and symptomatology.7

Patients with dry eyes may complain of ocular discomfort, light sensitivity, and watery eyes, and the condition can adversely affect quality of life.1 In severe cases, the inflammation associated with dry eye syndrome could potentially result in irreparable damage to the corneal surface.6 However, symptoms can be a relatively poor indicator of disease severity,3 8 and there is no gold standard test for determining the severity of dry eye disease.8

Clinical assessmentTests used to diagnose dry eye disease and to assess efficacy of treatments in clinical trials include:•  Measurement of tear film break-up time (the interval

between the individual’s last complete blink and the break up of the tear film) using fluorescein (shortened in dry eye disease)

•  Evaluation of tear quantity with Schirmer’s test (using a strip of filter paper placed under the lower eyelid)

•  Assessment of corneal and conjunctival epithelium integrity using stains and dyes

•  Evaluation of meibomian glands.6-11

A validated questionnaire, the Ocular Surface Disease Index (OSDI: 12 items graded on a scale of 0–4; see box), was developed by researchers at Allergan. It is used to assess recent symptoms and is thought to correlate moderately well with disease severity.8 12

Management of dry eye diseaseThe main goals of treatment include relief of symptoms and improved quality of life. There are no UK national guidelines on the management of the condition. The National Institute for Health and Care Excellence (NICE) Clinical Knowledge Summary recommendations on dry eye disease are adapted for UK primary care from US guidelines and the report of an international workshop.13 For initial management of the condition NICE recommends the following:•  Reviewing the response to any treatments that have

been tried•  Making changes to the environment at home or work

that increases evapouration of tears (such as computer use, air humidity)

•  Considering whether preservatives in topical eye medications might be a cause

It is a multifactorial disease with an inflammatory component that can cause damage to the ocular surface

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•  Reviewing any systemic medication that can induce or aggravate eye symptoms (such as antihistamines, β blockers, oestrogen therapy, tricyclic antidepressants, selective serotonin reuptake inhibitors, isotretinoin)9

•  Identifying underlying medical and surgical conditions associated with dry eye syndrome (such as allergic conjunctivitis, blepharitis, Sjögren's syndrome, previous ocular or eyelid surgery, radiation therapy).13

Topical therapyArtificial tears and ocular lubricants have traditionally been the mainstay of the management of dry eye disease. There is a large range of products available for treating dry eye listed in the British National Formulary. Many are classed as medical devices, which are subject to a different regulatory process from licensed medicinal products.14 15

Are topical therapies effective?The regular use of artificial tears or lubricating drops has been found to increase tear break-up time by a small amount (by a mean of 1.4 seconds, from a baseline of 4.7 seconds)10 and reduce signs of corneal damage as measured with rose Bengal staining (from a median rose Bengal score of 4.4 to 2.4 after one month's treatment).10 11 However, no significantly meaningful differences between products have been found.10-16 The absence of good

comparative evidence is hampered by the lack of standard definitions for disease severity and outcome measures, by differences in study design and duration of follow-up, and a limited number of comparative trials.11 16

Product choiceThe NICE Clinical Knowledge Summary recommends the following treatment where practical advice alone is insufficient:•  For mild or moderate symptoms, artificial tears•  For severe symptoms, preservative-free artificial tears,

perhaps with an ocular lubricant ointment to use at night•  For people with visible strands of mucus, consider

acetylcysteine drops (limited evidence).13

For people with mild or moderate symptoms, treatment with over-the-counter artificial tears alone may be sufficient.17 It is logical to start with a less viscous formulation at first as these are less likely to cause stinging and blurring. Hypromellose-containing drops are the most commonly used products, but they provide only temporary relief and so require frequent application. More viscous products (such as those containing carbomers or polyvinyl alcohol) need to be used less frequently but may be less well tolerated. Ointments containing paraffins can feel uncomfortable and cause blurring and so are more suitable for use at night.9 Other available products contain carmellose, hydroxypropyl guar, sodium hyaluronate, or lipids.

PreservativesPreservatives in eye drop formulations (such as benzalkonium chloride) can cause irritation or allergy. Although in vitro studies have suggested that prolonged contact with preservatives is problematic in dry eye, clinical studies are more mixed.18 This may be because dilution of preservative in the tear film may help to reduce the harmful effect. Preservative-containing preparations may be suitable for patients with mild dry eye and an otherwise healthy ocular surface.19 In more severe dry eye disease the use of preservative-free drops is more important because of reduced dilution in the tear film. Guidelines from the US and Canada suggest that a preservative-free preparation is preferable for patients using multiple drops on a daily basis (>4 times/day) or those who also use other eye drops in order to reduce total exposure to the preservative.9 19

Preservative-free preparations should be considered if a product causes irritation or if soft contact lenses are worn

OCULAR SURFACE DISEASE INDEX12

Have you experienced any of the following during the last week?• Eyes that are sensitive

to light• Eyes that feel gritty• Painful or sore eyes• Blurred vision• Poor vision

Have problems with your eyes limited you in performing any of the following during the last week?• Reading• Driving at night• Working with a computer

or bank machine (ATM)• Watching television

Have your eyes felt uncomfortable in any of the following situations during the last week?• Windy conditions• Places or areas with low

humidity (very dry)• Areas that are air

conditioned

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Preservative-free products are available as single-dose vials (some of which are resealable for use up to 12 hours later) and as multidose units. Preservative-free preparations should be considered if a product causes irritation or if soft contact lenses are worn.13

Compliance aidsThe ease of use of the product is an important consideration. For people with arthritic hands, single-dose units can be more difficult to use than multidose bottles. An eye drop dispenser or compliance aid (such as Opticare, ComplEye) may help some people.18

Local formulariesIn the absence of evidence to guide product choice and in an attempt to manage the prescribing of products for which there is a wide choice and price range, many NHS authorities have produced their own guidelines.20-24 In general, these recommend first line treatment with a generic or low cost brand of hypromellose (0.3–1%).

CostThe unit cost of artificial tears and ocular lubricants varies widely from around £1 for generic hypromellose to around £10 for some brands of preservative-free sodium hyaluronate that have a six month expiry date while in use. The overall cost of treatment is affected by whether or not a preservative-free product is used, the product expiry once in use, and frequency of use. Some formularies advise that it is only more cost effective to start with a preparation with a six month expiry date if the patient uses the product less often than four times daily.20

When to referIt may be appropriate to refer patients to an optometrist before an ophthalmologist. An optometrist can assess people with dry eye syndrome and advise on treatment.18 However, access to NHS commissioned optometry services is not comprehensive.13

The NICE Clinical Knowledge Summary recommends referring patients with the following:•  Moderate to severe eye pain or photophobia, marked

redness in one eye, or reduced visual acuity (same day referral)

•  Symptoms uncontrolled despite appropriate treatment for about four weeks

•  Diagnosis that requires specialist assessment•  Deterioriating vision•  Ulcers or other signs of corneal damage•  Associated disease that requires specialist management

(such as Sjögren's syndrome, eyelid deformities).13

NICE also recommends considering referral of patients who require a preservative-free topical eye product for more than four weeks. It provides no evidence to support this approach.13

Other treatments for dry eyeGiven that there is an inflammatory component to dry eye disease, anti-inflammatory and immodulatory treatments (including topical corticosteroids) have been

tried for patients in whom artificial tears and lubricants are ineffective.25 The use of corticosteroids is limited by their adverse effects.

Ciclosporin eye drop emulsion 0.1% (Ikervis) is marketed for treatment of severe keratitis in adults with dry eye disease that has not improved despite treatment with tear substitutes.26 Compared with vehicle, ciclosporin eye drops have been shown to improve signs of corneal surface damage but not symptoms.27 Within its licensed indication, it has been accepted for use by the Scottish Medicines Consortium and NICE.27 28 It must be initiated by an ophthalmologist or a healthcare professional qualified in ophthalmology.26

Other treatments that have been used to treat dry eye disease include autologous eye drops (derived from the patient's own blood serum),29 and the insertion of punctal plugs to block the lacrimal glands.30

Supplementation with polyunsaturated fatty acids (omega-3 and omega-6) has also been tried for anti-inflammatory effect, and because they can improve lacrimal and meibomian gland function. The authors of a systematic review included nine double blind randomised controlled trials (involving a total of 716 patients) assessing the effects of polyunsaturated fatty acids (from fish oil, buckthorn, evening primrose oil, flax seed, and borage oil).31 Supplementation improved the OSDI symptom score, relieved burning and eye watering, and reduced inflammatory response on the ocular surface, but had no effect on tear volume or ocular surface stability. Large scale randomised controlled trials are needed to confirm an effect.

ConclusionDry eye is a common condition, particularly among older women. It is a multifactorial disease with an inflammatory component that can cause damage to the ocular surface. Symptoms can range from mild and episodic to severe and disabling, but relate poorly to ocular disease severity. Management of dry eye includes practical measures (such as increasing humidity in the environment) and symptomatic treatment with artificial tears and ocular lubricants. There is a very wide range of ocular products available, and a proliferation of products that are classified as medical devices. This wide choice (and variation in cost) together with a lack of comparative evidence makes selecting the most appropriate product for a patient difficult. In the absence of comparative evidence of safety or efficacy it makes sense to start with the lowest cost preparations. Given the higher price associated with preservative-free formulations, local guidelines should be agreed to target their use to those groups of patients most likely to benefit. These are likely to include patients using drops more than four times per day and those with more severe dry eye disease.Cite this as: BMJ 2016;353:i2333Find this at: http://dx.doi.org/10.1136/bmj.i2333

This article was originally published in Drug and Therapeutics Bulletin (DTB 2016;54:9-12; doi:10.1136/dtb.2016.1.0378).DTB is a highly regarded source of unbiased, evidence based information and practical advice for healthcare professionals. It is independent of the pharmaceutical industry, government, and regulatory authorities, and is free of advertising.DTB is available online at http://dtb.bmj.com.

Consider referral if symptoms are uncontrolled despite appropriate treatment for about four weeks

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ENDGAMES For long answers go to the Education channel on thebmj.com @BMJEndgames

answ

ers

CASE REVIEW A rugby player’s finger injury1 Inability to actively flex the distal interphalangeal joint (DIPJ) is pathognomonic of rupture of the flexor digitorum profundus (FDP) tendon. To

test the FDP tendon function, isolate the DIPJ by holding the proximal interphalangeal joint (PIPJ) in extension, thereby preventing the action of the flexor digitorum superficialis (FDS).

2 “Jersey finger” or “rugger jersey finger.” It classically occurs when a tackler has hold of an opponent’s jersey. The DIPJ is forcibly hyperextended when the FDP muscle is fully contracted, leading to tendon rupture at its insertion into the distal phalanx.

3 The ring finger is affected in more than 75% of cases probably because of the ring finger’s prominence during flexion compared with the other fingers—it is longest in grip, which may subject it to greater forces.

4 The extent of tendon retraction proximally and the type of tendon avulsion. Tendon avulsion can affect the soft tissue only or a bone fragment as well.

5 Most are treated surgically. Early intervention (by 7-10 days) is essential when the tendon is retracted as far as the palm. Delay can lead to FDP contraction and scarring of the pulley system, making primary repair impossible. Tendon avulsions require primary tendon to bone repair. Bone fragments can be fixed with small fragment screws.

SPOT DIAGNOSIS Unilateral facial flushing precipitated by eatingFrey’s syndrome. This occurs after injury (during forceps delivery in this case) to auriculotemporal nerve fibres, which regenerate and erroneously stimulate the sweat glands or blood vessels instead of the parotid glands.

1 What key aspect of the clinical examination would confirm the diagnosis?2 What is the name of this injury (the name provides a clue to its mechanism)?3 Which finger is most commonly affected?4 How are these injuries classified?5 How are these injuries managed?Submitted by Thomas F M Yeoman and Philippa A RustPatient consent obtained.Cite this as: BMJ 2016;353:i1911

CASE REVIEW A rugby player’s finger injury

SPOT DIAGNOSISUnilateral facial flushing precipitated by eatingA healthy 7 year old girl born by forceps delivery presented with a lifelong history of unilateral facial flushing precipitated by eating (figure). What diagnosis correlates with these clinical findings?Submitted by Ella Daniels and Richard Watchorn

Parental consent obtained.Cite this as: BMJ 2016;352:i1377

We welcome contributions that would help doctors with postgraduate examinations. We also welcome submissions relevant to primary care. See thebmj.com/endgames

A 16 year old right hand dominant schoolboy presented to the emergency department with a painful, swollen right ring finger. Three days earlier he had injured his finger playing rugby and he thought the injury occurred while he was tackling an opponent. Although he was able to finish the game he has had discomfort and reduced movement in the finger since.

Ecchymosis and tenderness were noted over the distal phalanx on the palmar aspect of his hand, as well as some swelling and tenderness at the base of the ring finger (below). The finger had no neurovascular deficit and examination of the rest of the right hand was normal. No fracture was seen on a plain radiograph of the ring finger.

A 4 month old, preterm, exclusively breastfed baby presented with a two month history of erythematous, crusted plaques on her face (A) and anogenital region, irritability, and diarrhoea. Skin swabs isolated fully sensitive Staphylococcus aureus, but oral antibiotics and topical therapies did not work. Zinc deficiency was clinically suspected and oral zinc sulphate started. The rash resolved within 10 days (B). Blood tests confirmed low zinc (<2 µmol/L; reference 11-19). Maternal serum and breast milk zinc were low (10 µmol/L and 6.75 µmol/L; 7.2-10.9).

Transient neonatal zinc deficiency is caused by defective zinc secretion into breast milk. Zinc supplements should be started on the basis of clinical suspicion (infantile facial and anogenital rashes unresponsive to standard treatments) and continued until weaning.

Transient neonatal zinc deficiency

MINERVA A wry look at the world of research

The geriatrician’s scalpel“Too Much Medicine,” “Choosing Wisely,” “Less is More”: these are the slogans of a social movement for change in medicine, and its newly coined watchword is “deprescribing.” But an interview study of GPs in New Zealand shows that many are concerned about stopping certain drugs in elderly patients on polypharmacy (Int J Clin Pract doi:10.1111/ijcp.12780). The authors suggest that deprescribing guidelines may help to clarify evidence based medicine relating to controversial areas. This used to be known as “the geriatrician’s scalpel”—perhaps geriatricians can lead the way.

Intensive delirium“Throughout the interviews we found an overwhelming sense of complete bewilderment and fear expressed in nightmares, altered realities and false explanations,” said Lisa Hinton, who helped to record the experiences of patients admitted to intensive care units around the UK. The study was carried out with colleagues in the Health Experiences Research Group at Oxford University and is reported in PLoS One (doi:10.1371/journal.pone.0153775). But for a direct flavour of these patients’ experiences it’s best to go to their healthtalk website: a model for making experiences of illness real (http://bit.ly/1TvX9d9).

Do you want to live to 100?Only a third of old people living in Helsinki, Finland expressed a desire to live to the age of 100, and of those many qualified it with “provided I stay healthy.” A random questionnaire survey of 1405 people aged 75-96 years found that those who didn’t want to become centenarians mostly feared they would become disabled, life would be meaningless, or that they might become a burden to others, have loss of autonomy, pain, or loneliness. More positively, some felt that they had achieved all they wanted in life (Age Ageing doi:10.1093/ageing/afw059).

Online CBT: cost effective for health A Swedish study showed that internet based cognitive behavioural therapy (ICBT) can be an effective treatment for severe health anxiety, and the investigators now show that it is also cost effective (BMJ Open doi:10.1136/bmjopen-2015-009327). The 151 participants in this university based study comparing ICBT with internet based behavioural stress management were self referred. Both treatments led to significant reductions in gross total costs, costs of healthcare visits, direct non-medical costs, and costs of domestic work cutback (P=0.000-0.035). However, ICBT proved cheaper by £1518 per successful case.

Reasons for kids’ readmissionsA study of paediatric readmissions after emergency NHS hospital admission across England in 2009-10 finds that over half of the 9% readmitted were admitted for a different reason from the index admission (Arch Dis Child doi:10.1136/archdischild-2015-309290). As the authors conclude, this suggests that financial penalties for readmission are illogical.

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S K Mahil (satveer.mahil@kcl.ac.uk), W Alwan, P Banerjee, C L Lowry, consultant dermatologist, J Ross, S Hoque, Lewisham and Greenwich NHS Trust, London Parental consent obtained.Cite this as: BMJ 2016;352:i834Find this at: http://dx.doi.org/10.1136/bmj.i834

PROMs to reduce diabetes burden?When Swedish investigators interviewed 29 people living with both types of diabetes they found that “the most central aspect was to feel good, in the present and in the future, and not to be affected too much by diabetes and the workload of its management” (BMJ Open doi:10.1136/bmjopen-2015-010249). The project was aimed at developing patient reported outcome measures (PROMs) for diabetes, and it will be interesting to see how they reflect this ideal of “minimally disruptive care.”

Breathing germs from wasteCollecting garbage (or rubbish as we used to call it) involves breathing in microbes, and a Danish study finds that these become highly concentrated in the cabs of garbage trucks (or bin lorries as we called them). There are 111 times as many fungi and 7.7 times as many bacteria in the cab air as in the air outside (Ann Occup Hyg doi:10.1093/annhyg/mew021). Most of the fungi are Penicillium spp, and most of the bacteria are harmless.Oh, my old man’s a dustman,He wears a dustman’s hat,He breathes in lots of dustman’s germsBut he’s none the worse for that.Cite this as: BMJ 2016;353:i2414Find this at: http://dx.doi.org/10.1136/bmj.i2414