BMJ  2007;334 (23 June), doi:10.1136/bmj.39253.656134.3A

Editor's Choice

US editor's choice

Changing what we do

One way to measure whether a medical journal is of use to you is whether anything you read leads to changes (presumably improvements) in what you do. Sometimes new ideas are evidence-based and seem required once you know about them. Other times they are just good ideas, worth a try. This week's BMJ has some of each type.

If there is anyone out there still using lactated Ringer's solution for initial treatment of patients with diabetic ketoacidosis, it's probably time to stop. In an editorial, Ketan Dhatariya claims that some UK emergency room doctors and intensivists are still using Hartmann's solution (similar but not identical to the Lactated Ringer's used in the US), and explains all the reasons that favor normal saline instead (doi: 10.1136/bmj.39237.661111.80). Although no randomized controlled trials back up his statements, the logic is reasonably sound for the benefits of normal saline over a lactated solution.

One mistake commonly made in medicine (along with the rest of the world) is the "if it's good for some it must be good for all" attitude, or extrapolation error. Stephen Bolsin and colleagues discuss this with reference to the use of blockers and statins in non-cardiac surgery (doi: 10.1136/bmj.39217.382836.BE). Several trials have failed to prove that perioperative use of either of these is helpful in patients not already taking them, and the results of a large American trial are still to come. The authors advise that no patients undergoing non-cardiac surgery should be started on blockers or steroids routinely in the perioperative period until better evidence emerges.

This week's clinical review discusses the diagnosis and treatment of sciatica (doi: 10.1136/bmj.39223.428495.BE). B W Koes et al point out that the diagnosis is still a clinical one and that most patients with this painful problem get better over time. Lacking red flags that raise concerns about tumors, fractures, and other treatable causes, conservative treatment is probably indicated for the first month or two. Randomized controlled trials have shown some small benefits of surgery for patients who don't improve after an initial conservative treatment period, but the evidence is mixed and should be interpreted with caution.

Finally, Bruce Arroll and Karen Falloon recommend attending patients' funerals, for both personal and family benefits (doi: 10.1136/bmj.39251.616678.47). There is little evidence to support this practice, but they have found it rewarding and helpful. It demonstrates and continues care for the family and provides an opportunity for them to talk about the death with the doctor. We won't be seeing a randomized trial any time soon on this, but it sounds like a good idea to me.

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Relevant Articles

blockers and statins in non-cardiac surgery

Stephen Bolsin, Mark Colson, and Myles Conroy
BMJ 2007 334: 1283-1284. [Extract] [Full Text] [PDF]

Diabetic ketoacidosis

Ketan K Dhatariya
BMJ 2007 334: 1284-1285. [Extract] [Full Text] [PDF]

Diagnosis and treatment of sciatica

B W Koes, M W van Tulder, and W C Peul
BMJ 2007 334: 1313-1317. [Extract] [Full Text] [PDF]

Should doctors go to patients' funerals?

Bruce Arroll and Karen Falloon
BMJ 2007 334: 1322. [Extract] [Full Text] [PDF]