Editor's choice

Not so simple after all

From BMJ USA 2002;October:533

More is not always better, as controlled trials in this issue demonstrate. Quinn et al find that small hand lacerations heal just as well without sutures (BMJ USA p 556). Lenhardt et al show that intravenous catheters can be inserted more easily by warming the skin beforehand (BMJ USA p 572). Girou et al report that an alcohol-based solution cleans the hands just as well as antiseptic soap (BMJ USA p 572). Henry David Thoreau, sitting by Walden Pond and praising simplicity, nods in agreement.

But on closer examination, the material in this issue reminds us that things are not always so simple. Rapid responses to Quinn et al emphasize that the findings apply only to small, uncomplicated lacerations and that exploration is required first to exclude deep tendon and nerve injuries (BMJ USA p 558). The cover photo (below) of the August 10, 2002 issue of the BMJ (in which the Quinn study was published) was roundly criticized for depicting a laceration apt to involve deep structures, not the kind of simple injury the study addressed.

Something as simple as the office blood pressure measurement cannot be trusted, according to Little et al (BMJ USA p 549) and an accompanying editorial (BMJ USA p 541). These authors assert that "it is time to stop using high blood pressure readings documented by general practitioners to make decisions about treatment." Paci et al (BMJ USA p 559) reject the concern that mammography screening leads to increased mastectomies, because rates decreased in Florence, Italy after screening was introduced. Critics note that the downward trend was already under way before screening began. "The relevant question is whether the decline in the mastectomy rate is slower" with screening, writes Peter Gøtzsche (BMJ USA p 560).

White et al (BMJ USA p 566) encourage moderate drinking to reach the nadir of the U-shaped curve for alcohol consumption and mortality. But the idea that drinking is good for you is not so simple. Higher mortality with lower consumption may reflect the tendency of fatal diseases to diminish drinking, not the benefits of ethanol. Outrage over domestic violence propels the message that doctors should routinely screen for this problem, but Ramsay et al find little evidence to determine whether it does any good (BMJ USA p 561).

How simplistic we are to think that today's apprehension over vaccines, vocalized on talk shows and in parents' testimony on Capitol Hill, is a recent phenomenon. Wolfe and Sharp describe British towns rioting over the issue in 1853. The authors observe that societal concerns never really abated and that 19th century sentiments have "uncanny similarities" with modern arguments, reflecting "an unbroken transmission of core beliefs and attitudes" (BMJ USA p 579).

Mr. Thoreau praised simplicity, but Albert Einstein went further: "Everything should be made as simple as possible, but not simpler."

Articles cited in Editor's Choice are listed below, beginning with their BMJ USA page number:

BMJ USA p 556 Suturing versus conservative management (Quinn), http://bmj.com/cgi/content/full/325/7359/299

BMJ USA p 572 Local warming and insertion of peripheral venous cannulas (Lenhardt) http://bmj.com/cgi/content/abstract/325/7361/409

BMJ USA p 572 Efficacy of handrubbing with alcohol based solution (Girou) http://bmj.com/cgi/content/abstract/325/7360/362

BMJ USA p 558 Rapid responses, bmj.com/cgi/doi/10.1136/bmjusa.02100005

BMJ USA p 549 Comparison of agreement between different measures of blood pressure (Little) http://bmj.com/cgi/content/full/325/7358/254

BMJ USA p 541 How should we take blood pressure in clinical practice? (Pickering) bmj.com/cgi/doi/10.1136/bmjusa.02100003

BMJ USA p 559 Are breast cancer screening programs increasing rates of mastectomy? (Paci) http://bmj.com/cgi/content/full/325/7361/418

BMJ USA p 560 Rapid responses, bmj.com/cgi/doi/10.1136/bmjusa.02100006

BMJ USA p 561 Should health professionals screen women for domestic violence? (Ramsay) http://bmj.com/cgi/content/full/325/7359/314

BMJ USA p 579 Anti-vaccinationists past and present (Wolfe) http://bmj.com/cgi/content/full/325/7361/430