BMJ  2004;328:71 (10 January), doi:10.1136/bmj.328.7431.71

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What's new this month in BMJ Journals

An error reporting system in general practice

Ten UK general practices successfully carried out a trial of an error reporting scheme. The error rate was 75.6/1000 appointments. Most were administrative (missing casenotes, computer failure) and only 3% were clinical—mostly inaccurate notekeeping but including erroneous drug dosages. Sixty eight per cent of practice staff found the system acceptable. The next steps are to evaluate sensitivity, specificity, and stability and to establish whether such a scheme could be an agent for change.

Qual Saf Health Care 2003;12: 443-7[Abstract/Free Full Text]

Helicobacter is worth eradicating in reflux oesophagitis

A randomised controlled trial of long term omeprazole alone or with the addition of one week's triple therapy has shown that eradicating Helicobacter pylori eliminates gastric mucosal inflammation and provokes corpus glandular atrophy to regress. These findings are important as most cases of gastric cancer occur on a background of chronic gastritis with gland loss, and long term acid suppression could accelerate these changes. Previous concerns that eradicating H pylori could impair control of reflux have been discounted by this study—nor did eradication lead to a need for a higher dose of omeprazole. The authors recommend a course of triple therapy in all patients with reflux receiving long term acid suppression.

Gut 2004;53: 12-20[Abstract/Free Full Text]

Herbal skin creams may contain potent steroids

Researchers in Birmingham (United Kingdom) analysed 24 herbal creams purchased by parents of children with atopic eczema which they believed were effective. All but four contained steroids, which in 14 cases were classified as potent or very potent. All creams labelled Wau Wa and two called Muijiza contained clobetasol. Wau Wa probably contains 20% Dermovate (clobetasol propionate). The package insert suggested using it "all over," implying that an average 3 year old would receive the equivalent of 22 g of Dermovate weekly, which would carry a risk of adrenal suppression. An accompanying commentary (p 1032-3) calls for tighter regulatory control of herbal therapies.

Arch Dis Child 2003;88: 1056-7[Abstract/Free Full Text]

Surfer wiped out by predator fish A man who was surfing off the Portuguese coast was thrown from his wave when he experienced a sharp pain in his heel. A foreign body was removed, but continuing inflammation despite antibiotics led to x ray imaging two weeks later. This revealed part of the beak of a Belonid needlefish (top) posterior to the calcaneum (bottom). This fish can leap out of the water at high speed but is not usually found in European waters. Br J Sports Med 2003;37: 537-9[Abstract/Free Full Text]

 

Managing osteoarthritis in the knee

1. The optimal management of knee OA requires a combination of non-pharmacological and pharmacological treatment modalities
   
2. The treatment of knee OA should be tailored according to:
   
   1. Knee risk factors (obesity, adverse mechanical factors, physical activity)
      
   2. General risk factors (age, comorbidity, polypharmacy)
      
   3. Level of pain intensity and disability
      
   4. Sign of inflammation—for example, effusion
      
   5. Location and degree of structural damage
      
   
   
3. Non-pharmacological treatment of knee OA should include regular education, exercise, appliances (sticks, insoles, knee bracing), and weight reduction
   
4. Paracetamol is the oral analgesic to try first and, if successful, the preferred long term oral analgesic
   
5. Topical applications (NSAID), capsaicin) have clinical efficacy and are safe
   
6. NSAIDs should be considered in patients unresponsive to paracetamol. In patients with an increased gastrointestinal risk, non-selective NSAIDs and effective gastroprotective agents, or selective COX 2 inhibitors should be used
   
7. Opioid analgesics, with or without paracetamol, are useful alternatives in patients in whom NSAIDs, including COX 2 selective inhibitors, are contraindicated, ineffective, and/or poorly tolerated
   
8. SYSADOA (glucosamine sulphate, chondroitin sulphate, ASU, diacerein, hyaluronic acid) have symptomatic effects and may modify structure
   
9. Intra-articular injection of long acting corticosteroid is indicated for flare of knee pain, especially if accompanied by effusion
   
10. Joint replacement has to be considered in patients with radiographic evidence of knee OA who have refractory pain and disability
    

Updated recommendations on managing osteoarthritis in the knee come from the expert standing committee for international clinical studies including therapeutic trials (ESCISIT). They are based on a literature search, level of evidence scores, expert review, and a Delphi technique.

Ann Rheum Dis 2003;62: 1145-55[Abstract/Free Full Text]

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