What's new this month in BMJ JournalsBMJ 2004; 328 doi: https://doi.org/10.1136/bmj.328.7431.71 (Published 09 January 2004) Cite this as: BMJ 2004;328:71
- Harvey Marcovitch, BMJ syndication editor ()
An error reporting system in general practice
Ten UK general practices successfully carried out a trial of an error reporting scheme. The error rate was 75.6/1000 appointments. Most were administrative (missing casenotes, computer failure) and only 3% were clinical—mostly inaccurate notekeeping but including erroneous drug dosages. Sixty eight per cent of practice staff found the system acceptable. The next steps are to evaluate sensitivity, specificity, and stability and to establish whether such a scheme could be an agent for change.
Qual Saf Health Care 2003;12: 443-7
Helicobacter is worth eradicating in reflux oesophagitis
A randomised controlled trial of long term omeprazole alone or with the addition of one week's triple therapy has shown that eradicating Helicobacter pylori eliminates gastric mucosal inflammation and provokes corpus glandular atrophy to regress. These findings are important as most cases of gastric cancer occur on a background of chronic gastritis with gland loss, and long term acid suppression could accelerate these changes. Previous concerns that eradicating H pylori could impair control of reflux have been discounted by this study—nor did eradication lead to a need for a higher dose of omeprazole. The authors recommend a course of triple therapy in all patients with reflux receiving long term acid suppression.
Gut 2004;53: 12-20
Herbal skin creams may contain potent steroids
Researchers in Birmingham (United Kingdom) analysed 24 herbal creams purchased by parents of children with atopic eczema which they believed were effective. All but four contained steroids, which in 14 cases were classified as potent or very potent. All creams labelled Wau Wa and two called Muijiza contained clobetasol. Wau Wa probably contains 20% Dermovate (clobetasol propionate). The package insert suggested using it “all over,” implying that an average 3 year old would receive the equivalent of 22 g of Dermovate weekly, which would carry a risk of adrenal suppression. An accompanying commentary (p 1032-3) calls for tighter regulatory control of herbal therapies.
Arch Dis Child 2003;88: 1056-7
Managing osteoarthritis in the knee
The optimal management of knee OA requires a combination of non-pharmacological and pharmacological treatment modalities
The treatment of knee OA should be tailored according to:
a.Knee risk factors (obesity, adverse mechanical factors, physical activity)
b.General risk factors (age, comorbidity, polypharmacy)
c.Level of pain intensity and disability
d.Sign of inflammation—for example, effusion
e.Location and degree of structural damage
Non-pharmacological treatment of knee OA should include regular education, exercise, appliances (sticks, insoles, knee bracing), and weight reduction
Paracetamol is the oral analgesic to try first and, if successful, the preferred long term oral analgesic
Topical applications (NSAID), capsaicin) have clinical efficacy and are safe
NSAIDs should be considered in patients unresponsive to paracetamol. In patients with an increased gastrointestinal risk, non-selective NSAIDs and effective gastroprotective agents, or selective COX 2 inhibitors should be used
Opioid analgesics, with or without paracetamol, are useful alternatives in patients in whom NSAIDs, including COX 2 selective inhibitors, are contraindicated, ineffective, and/or poorly tolerated
SYSADOA (glucosamine sulphate, chondroitin sulphate, ASU, diacerein, hyaluronic acid) have symptomatic effects and may modify structure
Intra-articular injection of long acting corticosteroid is indicated for flare of knee pain, especially if accompanied by effusion
Joint replacement has to be considered in patients with radiographic evidence of knee OA who have refractory pain and disability
Updated recommendations on managing osteoarthritis in the knee come from the expert standing committee for international clinical studies including therapeutic trials (ESCISIT). They are based on a literature search, level of evidence scores, expert review, and a Delphi technique.
Ann Rheum Dis 2003;62: 1145-55
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