MinervaBMJ 2003; 327 doi: https://doi.org/10.1136/bmj.327.7421.998 (Published 23 October 2003) Cite this as: BMJ 2003;327:998
Respect for the four principles of medical ethics, and autonomy in particular, should remain at the heart of ordinary medicine, according to an editorial written by a doctor in the Journal of Medical Ethics ( 2003;29: 265-6). He describes how he had to fight off the hordes of medical staff and friends who tried to convince him to have a blood transfusion at a time of acute injury, even though he was medically stable. He concludes from his experience in hospital that many doctors still lack any concept of what it is to respect a patient as a person.
Trials from specialist centres indicate that given the choice of immediate angioplasty or immediate thrombolysis for an acute myocardial infarction, angioplasty comes out on top. Wondering if the same holds true if patients have to be transferred to another place to have the angioplasty, the authors of a meta-analysis say angioplasty is still the winning option. Organising ambulance systems and developing adequate capacity to perform primary percutaneous coronary interventions are what counts now ( Circulation 2003;108: 1809-14).
In a prospective study, older women with breast cancer were randomly allocated to receive either conventional follow up or “case management” by nurses for the first 12 months after diagnosis. More women in the intervention group stated that they had a real choice in their treatment, and this group also received significantly more breast conserving surgery, radiotherapy, and breast reconstruction surgery, and more of them had normal arm function two months after surgery. It may be a small study, but the results speak for themselves ( Journal of the American Geriatrics Society 2003;51: 1252-9).
In the United Kingdom it's referred to as the “August phenomenon”; in the United States it's July. That's the time of year when the inexperience of junior doctors might be blamed for influencing patient outcomes. But in a study of what happened in 38 US intensive care units, the authors found no evidence for a problem ( Journal of General Internal Medicine 2003;18: 639-45). The odds of death and length of stay were similar from July though to September, although the stays were shorter in non-teaching hospitals.
National spending for all antidepressants increased by a whopping 600% during the 1990s, but recent evidence indicates that almost 50% of patients stop taking their medication as early as three months after starting it. A writer in Drug Benefit Trends ( 2003;15: 32-3) struggles with the issue of whether using antidepressants as placebo is good practice, while remaining concerned about the level of depression that goes undetected and undertreated.
People in atrial fibrillation usually stop taking their anticoagulation medication before undergoing endoscopic investigations. A six year review of what happened to 987 patients within 30 days of their endoscopy identified 12 strokes (1.06% per procedure). The rate ranged from 0.31% for uncomplicated cases to 2.93% for complex patients undergoing endoscopies combined with other procedures or who had other morbidities. The usual suspects increased the risk of stroke by almost tenfold: age, previous stroke, hypertension, high cholesterol, and family history of vascular disease ( Neurology 2003;61: 964-8).
A no-name tuberculosis tracking system has proved useful in a community where TB is rife, but where people do their utmost to avoid identification. The system was developed by public health workers in Delaware, where migrant poultry workers enter the US without documentation and assume multiple identities. Completion rates for treatment of latent TB infection in this community rose from 48% to 64% two years after the programme was implemented ( American Journal of Public Health 2003;93: 1637-9).
Commenting on a study in Chest ( 2003;124: 1192-4)which adds to the more than 10 year controversy about whether angiotensin converting enzyme inhibitors and aspirin interact in patients with heart failure, a cardiologist says that taken altogether, the evidence for a significant interaction is minimal in heart failure as long as low dose aspirin is used. Whether other anticoagulants will ultimately take the place of aspirin in people with atherosclerosis is another matter.
A study of intravenous medication errors identified an astounding 265 errors made during an observation of 483 drug preparations in two UK hospitals. The most common error was injecting bolus doses faster than the recommended speed of 3-5 minutes. The causes of the errors were put down to the lack of perceived risk, poor role models, and the available technology. Of the errors, 1% were potentially severe and 19% were potentially minor ( Quality and Safety in Health Care 2003;12: 343-8).
A biodegradable device that could provide multidose drug delivery offers potential advantages to people who require pulsatile drug release. The implantable microchips described in Nature Materials (advance online publication 19 October 2003, doi:10.1038/nmat998) are 1.2 cm in diameter and hold 36 reservoirs that could each be filled with a different chemical. Different drugs could be released at intervals by using different molecular masses or materials for the membranes that cover the reservoirs.
When developers of family planning services interviewed clinic users, they received more comments about the waiting room than any other aspect of the service. The comments were almost exclusively negative. The room was described as uncomfortable, insufficiently confidential, and lacking refreshment and entertainment. Apart from this, most clients said they were happy with the clinical consultation ( Journal of Family Planning and Reproductive Health Care 2003;29: 199-203).
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