BMJ  2004;329:370 (14 August), doi:10.1136/bmj.329.7462.370

BMJ family highlights

What's new this month in BMJ Journals

Iron deficient patients are underinvestigated and diagnosis is delayed

General practitioners investigated fewer than half the 603 patients presenting to them with iron deficiency anaemia, and a fifth were unwilling or unfit for further testing, a community based study has found. Of the 217 offered investigation within three months, 33 refused and 55 had a major disease, including 27 with gastrointestinal malignancy, 10 with active peptic ulcer and five with coeliac disease. After one year, 263 still had no diagnosis; of these, 40% were still anaemic. The eventual prevalence of malignancy was 11%, similar to that found in hospital studies, and diagnosis was delayed in a third of cases. Many of the patients had not been prescribed iron. The authors advise a full course of iron therapy and retesting for all, as recommended by the British Society for Gastroenterology.

Postgrad Med J 2004;80: 405-10[Abstract/Free Full Text]

Parents forget giving informed consent for neonatal research

When questioned 18 months after being entered into a randomised controlled trial involving 99 newborn babies, 12 parents could not recall being approached for consent nor that their child had participated in a study. Six recalled consenting but were unsure if their child had been entered. This was despite a single researcher having given a detailed verbal description and having supplied a printed information sheet when consent was sought, and given, by all of them. Although only 8% of all the parents regretted being part of a trial, nearly a third stated that they had understood little or none of the information provided. The authors suggest a strategy for ensuring that consent is maintained over time to avoid distress or mistrust, and they call for work with patient groups to look at how the process of participation in trials can be improved.

Arch Dis Child Fetal Neonatal Ed 2004;89: F321-4[Abstract/Free Full Text]

Doubling inhaled steroids doesn't control asthma exacerbation

In a double blind randomised trial, adults and adolescents with asthma who were maintained on inhaled budesonide were assigned to double their inhaled dose or to take their normal dose and an inhaled placebo at the first signs of an exacerbation of symptoms, a fall in peak flow, or increased use of a bronchodilator. Doubling the steroid dose did not change outcome in those who complied with their maintenance prescription. The study confirms the caution already expressed in the British Thoracic Society's guidelines. The authors recommend a strategy of careful monitoring, prescription of a short course of oral steroids, or possibly briefly using much higher doses of budesonide (> 2000 µg).

Thorax 2004;59: 550-6[Abstract/Free Full Text]

Low dose steroids have no long term benefit in rheumatoid arthritis

Patients with rheumatoid arthritis, maintained on sulphasalazine, who had been randomly assigned to take prednisolone 7 mg daily or placebo for two years had no difference in clinical and radiological outcomes and in laboratory measures. Adverse events due to steroids were rare, with six patients discontinuing treatment compared with two taking placebo, but 90 of 257 eligible patients had declined to participate, half of them because they did not want to take steroids. The authors say that low dose steroids have no role in the routine management of rheumatoid arthritis treated with conventional disease modifying drugs.

Ann Rheum Dis 2004;63: 797-803[Abstract/Free Full Text]

Spontaneous orbital bruising may indicate raised intracranial pressure A young woman presented with acute spontaneous periorbital bruising associated with a few days of headache, vomiting, photophobia, and eventually neck stiffness. Correct diagnosis was delayed by her history of migraine and by several doctors mistakenly assuming she had been assaulted. Computed tomography of her brain was consistent with a dural sinus thrombosis, including a small frontal lobe haemorrhage. J Neurol Neurosurg Psychiatr 2004;75: 1192-3[Abstract/Free Full Text]

Shattered vehicle mirrors may cause eye injuries Clinicians from Mooorfields Eye Hospital, London, report that two drivers sustained penetrating eye injuries when glass from a broken external rear view mirror entered through the open side window. Both events occurred after contact between the back of the mirror and an oncoming vehicle. The authors recommend driving with the side window up and urge manufacturers to consider repositioning external mirrors or replacing glass with a suitable plastic. Br J Ophthalmol 2004;88: 969-70[Free Full Text] Credit: MARGARET COOTER

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Spontaneous orbital bruising

Andrew B Clymo
bmj.com, 13 Aug 2004 [Full text]

CT error

tom heafield
bmj.com, 14 Aug 2004 [Full text]