BMJ 7068

BMJ NO 7068 Volume 313 Saturday 23 November 1996

This Week in BMJ | Editor's Choice | Press releases

Editorials: 1273 Lipids and secondary prevention of ischaemic heart disease Christopher D Byrne, Sarah H Wild
1274 Allocating budgets for fundholding and prescribing Azeem Majeed
1275 Cervical sampling devices Peter Sasieni
1276 Home birth Nachiel P Springer, Chris Van Weel
1277 The future of the NHS Chris Ham
1278 A gene for Parkinson's disease? Christopher Hawkes

News: HIV positive surgeon allowed to operate * Counselling lacks sound evidence * Permanent vegetative state * Should they keep taking the medicine? Triglyceride concentrations and cardiac risk * Scientists close to Parkinson's disease gene * The 48 hour week * Plans to improve emergency services * Health gains status in EU The rise of organ tourism * Israel loosens kidney donation rules * A tougher patient's charter * Australian clampdown on foreign doctors * Ontario doctors stand firm

Papers

1285 Relation between sampling device and detection of abnormality in cervical smears: a meta-analysis of randomised and quasi-randomised studies Frank Buntinx, Marleen Brouwers

1291 Conservative management of mechanical neck pain: systematic overview and meta-analysis Peter D Aker, Anita R Gross, Charles H Goldsmith, Paul Peloso

1297 Effect of population mixing and socioeconomic status in England and Wales, 1979-85, on lymphoblastic leukaemia in children C A Stiller, P J Boyle

1300 Absence of oats toxicity in adult coeliac disease Usha Srinivasan, Niamh Leonard, Eileen Jones, Donald D Kasarda, Donald G Weir, Cliona O¹Farrelly, Conleth Feighery

General Practice

1302 Prospective regional study of planned home births J Davies, E Hey, W Reid, G Young, for the Home Birth Study Steering Group

1306 Collaborative survey of perinatal loss in planned and unplanned home births Northern Region Perinatal Mortality Survey Coordinating Group

1309 Outcome of planned home and planned hospital births in low risk pregnancies: prospective study in midwifery practices in the Netherlands T A Wiegers, M J N C Keirse, J van der Zee, G A H Berghs

1313 Home versus hospital deliveries: follow up study of matched pairs for procedures and outcome Ursula Ackermann-Liebrich, Thomas Voegeli, Kathrin Gunter-Witt, Isabelle Kunz, Maja Zullig, Christian Schindler, Margrit Maurer, Zurich Study Team

Education & Debate

1319 Promoting efficiency in the NHS: problems with the labour productivity index John Appleby
1321 Writing in English for an international readership John Kirkman

1323 Commentary: Freedom of expression should be preserved Iona Heath, Bjorn Nilsson

1324 Grand Rounds - Nottingham City Hospital: A rare cause of superior vena cava obstruction T W Harrison
1322 Correction: Importance of accurate assessment of fetomaternal haemorrhage after late abortions Imelda Bromilow and others

1327 Obituaries: Sir B Warren, E W Colley, D A Hack, E C 0 Jewesbury, M Lack, E F Marx, D T Stewart, G Way

1328 Letters: 1328 Pulmonary artery catheterisation T J Dexter; R Lazarus; W Konarzewski
1329 Tertiary cancer services M Paul; B Tennison and others; M A Richards and J C Parrott
1330 Patients should be given more information about drugs during consultations T P Schofield
1330 Cardiac troponin T in unstable angina A S Wierzbicki and T M Reynolds; R L Kennedy; P Stubbs and others;
1331 Health for all by the year 2000 F S Antezana; A R P Walker and others
1331 Code of practice on managing tuberculosis is satisfactory P Ormerod and others
1332 Sudden infant death syndrome A Macfarlane; S Logan and others; G A De Jonge and A C Engelberts; P J Fleming and others
1334 Recorded consultations for children under 5 have increased considerably in general practice A R Del Mar
1334 Ambulatory monitoring of blood pressure should be restricted to scientific research M Brueren
1334 Intracytoplasmic sperm injection W Buckett and others; T R Moss
1335 Post-exposure prophylaxis after needlestick injuries would require change in management T J Neal and O Harvey
1335 Liberal Democrats' health policy merited more detail S Hughes
1335 Correction: Predicting which psychiatric patients are at risk of suicide S Hatcher

1336 Medicopolitical Digest: Extracontractual referrals * White paper's three projects * Complaints to Ombudsman

1337 Soundings: Every package needs a government health warning Trisha Greenhalgh;
A professional opinion? Liam Farrell

1338 Personal View: Symptomatic prescribing reappraised Peter Hays

1339 Medicine and the Media: The enemy and the experiment Kenton Morgan

1340 Medicine and Books: Bernard Dixon: Microbe Hunters - Then and Now (Ed Hilary Koprowski, Michael B A Oldstone)
J A Muir Gray: Science on Trial: The Clash of Medical Evidence and the Law in the Breast Implant Case (M Angell)
Ann Bowling: Health Interview Surveys. Towards international harmonisation of methods and instruments (Eds A de Bruin, H S J Picavet)
Ray Fitzpatrick: Measuring the Quality of Life: From Theory to Practice (Soren Ventegodt)

1342 Minerva

S2 Career Focus (Classified supplement): Certify a specialist Stella Lowry

Editor's choice

On not knowing about the everyday

Today in every town, doctors will be taking cervical smears, treating neck pain, and answering questions about the possibility of women giving birth at home; and in the larger towns doctors will be inserting catheters into the pulmonary arteries of seriously ill patients. Patients will naturally assume that the doctors know exactly what they are doing. "Perhaps doctors are uncertain," they may think, "about the implications of all these genes being discovered, and clearly they don't know much about whether 'mad cow disease' can spread to man. But surely they know about these everyday things."

Today's journal shows not only that doctors are uncertain about these activities but also that despite years of studies - and huge financial investment we haven't done research that will answer the questions adequately. Cervical screening was described 50 years ago, and about 1 5 000 cervical smears are taken every day in Britain. Yet still we don't know which is the best device to use to get the smear. A systematic review does provide advice but also exposes the poverty of the evidence (p 1285). Neck pain affects half of us during our lifetimes, and there are a plethora of treatments, including manual treatments, physical medicine methods, drugs, and patient education. But the final conclusion of a systematic review is that "no treatments have been studied in enough detail to assess either efficacy or effectiveness adequately (p 1291)." Sometimes doctors cannot be confident of answers to questions because they are intrinsically hard to answer. It's probably impossible to conduct randomised controlled trials of home birth not only because many women are reluctant to be randomised in such circumstances but also because huge studies would be needed because the outcome is usually good for mother and baby. Hence we have to resort to observational studies, and four in this week's journal suggest that home birth can be a safe option if women are well selected (pp 1302, 1306, 1309, and 1313). The argument over the possible dangerousness of pulmonary artery catheters began in JAMA, but our editorial (28 September, p 763) on the paper has elicited a brisk correspondence (p 1328). Patients who are given such catheters have a poor outcome, but that's not surprising because they are only inserted into desperately sick patients. But do they make things worse? We don't know, but an anaesthetist from Colchester argues that one of the bad things about the catheters is that "they introduce an element of pseudoscience into the care of critically ill patients, which is an area of medicine where we urgently need a cool and scientific reappraisal of what we are doing."