Research Paper of the Year: Simple interventions that save livesBMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d1202 (Published 28 February 2011) Cite this as: BMJ 2011;342:d1202
This year’s judges have to choose between three randomised controlled trials, each of which finds that a relatively simple intervention could save many lives. The research topics ranged from screening for colorectal cancer and reducing bleeding in injured patients to treating malaria in children (see box).
Research questions of the shortlisted papers
Does one-off screening with flexible sigmoidoscopy for 55 to 64 year olds cut the incidence of colorectal cancer and related mortality over 11 years?
Does a short, low cost, course of tranexamic acid reduce adults’ mortality from bleeding within a month of severe injury?
For African children in hospital with severe falciparum malaria, does parenteral artesunate save more lives than parenteral quinine?
Elizabeth Loder (clinical research editor) and I looked separately at all 150 or so nominated papers and then met to discuss our choices. We hadn’t planned to shortlist only trials: there were plenty of great papers whose research questions were appropriately and robustly answered with observational study designs. But, in the end, we were clear that these three papers more than met the criteria for this award: originality; scientific robustness; international relevance; potential to help doctors make better decisions about clinical practice, public health, research methodology, or health policy; and potential to improve health outcomes for patients or populations.
Wendy Atkin and colleagues investigated whether a one-off flexible sigmoidoscopy could be a cost-effective and acceptable method of population screening for colorectal cancer. Their trial in 14 UK centres randomised more than 170 000 men and women aged 55-64 years to an offer of flexible sigmoidoscopy screening or to no invitation.1 After 11 years the incidence of colorectal cancer was reduced by 33% and related mortality by more than 40% in those in the screening group. The numbers needed to be screened to prevent one colorectal cancer diagnosis or death by the end of the study period were 191 (95% CI 145-277) and 489 (343-852), respectively.
Some of the participants were already in the national bowel cancer screening programme based on faecal occult blood testing that was being rolled out across England, but the authors’ sensitivity analysis excluding cancers picked up by national screening made no difference to the trial’s results. This study, along with economic analyses and a handful of ongoing trials from other countries, will soon enable policy makers to choose the best way to screen populations for what is the third commonest cancer worldwide.
Meanwhile, injuries from road crashes and other incidents are on course to be the third leading cause of death and disability worldwide by 2020, and a third of deaths in hospital from trauma are caused by haemorrhage. Might tranexamic acid, a low cost haemostatic drug already known to reduce the need for blood transfusion by a third in elective surgery, also cut mortality among trauma patients? Haleema Shakur and collaborators compared infused tranexamic acid against placebo among more than 20 000 recently injured patients in 40 countries who had major bleeding or were at risk of it. The drug significantly reduced both the overall mortality in hospital over the next month (14·5% in the tranexamic acid group compared with 16·0% with placebo; relative risk 0·91, 95% CI 0·85-0·97; P=0·0035) and deaths owing to bleeding (4·9% v 5·7%).2 The authors called for tranexamic acid to be available to doctors treating trauma patients in all countries, and said it should be considered for the WHO List of Essential Medicines.
Quinine for treating malaria has gone in and out of favour over the past 400 years, with its use resurging each time resistance develops to newer treatments. It’s a cheap and effective drug but it often causes hypoglycaemia and is locally toxic when injected intramuscularly, and the risk of severe hypotension demands very careful supervision when it is given intravenously. Parenteral artesunate, on the other hand, is safe and simple to administer and is known—at least from trials in southeast Asian adults—to reduce malaria mortality more effectively than quinine. Would the same hold true for African children? Arjen Dondorp and colleagues’ trial found that, indeed, parenteral artesunate led to significantly lower mortality than parenteral quinine in children in hospitals in nine African countries.3 The relative reduction in mortality was 22·5% (95% CI 8·1-36·9) and the overall number needed to treat to prevent one death was 41 (25-112).
The judges with the unenviable task of selecting just one Research Paper of the Year are Sally Davies, chief medical officer (interim), director general of research and development and chief scientific adviser for the Department of Health and NHS; Zulfiquar Bhutta, Husein Laljee Dewraj professor and chairman, department of paediatrics and child health, Aga Khan University Medical Center, Karachi, Pakistan; Fiona Godlee, BMJ editor in chief; and Melba Gomes, the winner of last year’s award and scientist, Special Programme for Research and Training in Tropical Diseases, WHO Geneva.
Cite this as: BMJ 2011;342:d1202
The Research Paper of the Year award is sponsored by GlaxoSmithKline. For more about the BMJ Group awards go to http://groupawards.bmj.com.