Answers to big questions

BMJ 2000; 320 doi: (Published 24 June 2000) Cite this as: BMJ 2000;320:0

This week's journal offers answers—admittedly provisional—to some big questions. What advice should be offered to a woman who has a normal colposcopy result after a smear shows low grade cervical abnormalities? What is the best age to have children? Should children who live in parts of the world where helminths are common be treated routinely? How can a health system minimise adverse events? Were the results of the United Kingdom prospective diabetes study (UKPDS) hyped, and if so why?

Some 250 000 women in Britain each year have mild or borderline abnormalities on cervical smears. About half the women who are referred for colposcopy have a normal cervix. It has not been clear how best to manage these women, and many have repeated colposcopies. A large study from Birmingham shows that it is safe to discharge the women who have a normal cervix and then a negative or borderline smear test result on their first visit back to the clinic (p 1693).

The meaning of life may famously be 42 (from The Hitchhiker's Guide to the Galaxy), but the question of the optimum age to have children cannot be so easily answered. A Danish study of over one million births shows that the chances of stillbirth, miscarriage, and fetal loss increase considerably with maternal age to the point that half of pregnancies at age 42 (a coincidence) ended in fetal loss (p 1708). An editorial argues, however, that biological disadvantage may be balanced by social advantage (p 1681).

One third of the world's population is infected with intestinal helminths, and the World Bank believes that mass treatment of children is a good strategy to improve health. A systematic review from Liverpool finds that the evidence is not convincing (p 1697), but a huge cluster randomised controlled trial is underway in India. The pilot study of 20 000 children has been completed. (That's Richard Peto's idea of a pilot study. God bless him.)

England's chief medical officer, Liam Donaldson, has produced a report on how to improve safety in the NHS, and an editorial praises it as “an excellent and readable report that should be taken up by all involved in health care” (p 1683). The major recommendation is for a national mandatory reporting scheme for adverse events but also central is the idea of creating a “safety culture” rather than a “blame culture.” Unfortunately, as Jane Smith describes (p 1738), Donaldson's boss spun the report to emphasise the opposite message.

Finally, James McCormack and Trisha Greenhalgh take authors, journal editors, and the wider scientific community to task for hyping the results of the UKPDS, the huge study on type 2 diabetes reported in 1998 (p 1720). They identify many types of bias, including the “just keep taking the tablets” bias.


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