Smoking, alcohol, and the north-south divide . . . and other stories

BMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j1240 (Published 16 March 2017) Cite this as: BMJ 2017;356:j1240

Cassandra's regret

Cassandra, you may recall, was given the power of foretelling the future. Medicine tries to tell the future through genomics, risk scores, telomeres, biochemical markers, and even the faecal microbiome. But when Gerd Gigerenzer and a colleague conducted surveys in Germany and Spain, they found that between 85% and 90% of people would not want to know about upcoming negative events, and 40% to 70% prefer to remain ignorant of positive events. Only 1% of participants consistently wanted to know. Their paper on regret theory (Psychol Rev doi:10.1037/rev0000055) is bound to become a classic.

Pre-eclamptic toxaemia and cardiovascular disease

Pre-eclamptic toxaemia in pregnancy is an example of a “Cassandra condition,” one which increases the future risk of bad events in ways we don't understand and can't do much about. A systematic review puts together data on more than 250 000 women with pre-eclamptic toxaemia and 6 million women without (Circ Cardiovasc Qual Outcomes doi: 10.1161/CIRCOUTCOMES.116.003497). Pre-eclampsia is associated with a fourfold increase in future incidence of heart failure and a twofold increased risk in coronary heart disease, stroke, and death because of coronary heart or cardiovascular disease.

Put your reliance in the James Lind Alliance

The James Lind Alliance brings together patients and the clinicians who look after them to set priorities for future research. Pressure ulcers are an example of a common, distressing, neglected, high cost problem that is grossly under-researched. It isn't easy to bring together a group of mostly frail elderly patients and give them a real say in what matters to them, but this is what the alliance accomplished, and their account of the process (Res Involv Engage doi:10.1186/s40900-016-0026-y) provides insights that should encourage others to look at other unsexy areas of real need.

England: healthier in the middle

Ask an English southerner where the north begins, and the answer will be Watford. Ask a northerner, and it will be Manchester or Sheffield. The bit in between is often referred to as the Midlands, though nobody quite knows where they begin or end either. A survey of smoking and excessive alcohol consumption in England shows that both these vices are most prevalent above the Manchester-Sheffield line, and increase again south of Watford (BMJ Open doi: 10.1136/bmjopen-2016-014210). It's in the middle of England that virtue resides.

Sharing decisions about heart valves

When the Iron Curtain fell around 1990, millions of people experienced decisional conflict for the first time. Overnight, there was more than one kind of car to buy, a variety of different televisions, a choice of bottled gherkins. When patients were given a decision aid and asked to choose between mechanical and biological replacement heart valves, they too experienced decisional conflict (Circ Cardiovasc Qual Outcomes doi: 10.1161/CIRCOUTCOMES.117.003549; Circ Cardiovasc Qual Outcomes doi: 10.1161/CIRCOUTCOMES.116.003178.). But despite this, their mental wellbeing was greater than in the group not given the aid: they were more knowledgeable, better informed, and less anxious or depressed.

Diagnostic studies: what are they talking about?

Looking at 103 randomised trials of tests to determine treatments, a study (BMC Med Res Methodol doi:10.1186/s12874-016-0286-0) found that 98 failed to provide all the components necessary to characterise test treatment strategies. Only five trials provided a description of tests and test methods, treatment methods, and decision making across all study groups, but none of these also provided a complete care pathway diagram.

Drones to deliver shocks

American eagles mistaking delivery drones for prey may be in for a shock. An article in Circulation (doi: 10.1161/CIRCULATIONAHA.116.026318) describes how a drone network could be capable of flying an automated external defibrillator to the scene of an out-of-hospital cardiac arrest in rural parts of the US. According to mathematical modelling, this could deliver the machine to a pulseless patient 3-10 minutes faster than a 911 response vehicle.

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