This week in the BMJ
Volume 324, Number 7343, Issue of 20 Apr 2002Diabetes is not as fatal as coronary heart disease
Diabetes is not as fatal as coronary heart disease
Patients with type 2 diabetes are at lower risk of death from all
causes, including cardiovascular disease, than patients with
established coronary heart disease alone. This challenges the widely
held view that patients with diabetes have as high a cardiovascular
risk as patients with established coronary heart disease. On the basis
of their cross sectional and cohort study, Evans and colleagues (p 939)
advise that these results have important implications for clinical
practice: "We should be cautious about basing treatment decisions on
individual risk factors for cardiovascular disease in isolation."
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Richer women have caesarean sections
Women from families with higher incomes and higher levels of education
have caesarean sections more often than those with lower incomes or of
a lower educational level. In Brazil, 55% of women earning more than
$1000 (£700; 
1145) a month have a caesarean section, well above the
15% maximum recommended by the World Health Organization. A study by
Béhague and colleagues (p 942) shows that the fear of
substandard care is the main reason behind many women's preference,
not lack of knowledge or fear of the physiological consequences of
vaginal delivery, as was previously thought. The authors call for
better educational interventions to educate doctors and patients about
the risk factors associated with caesarean sections.
In Latin America 90% of women have an episiotomy
A study of over 400 000 deliveries in 16 Latin American countries by
Althabe and colleagues (p 945) shows that nine of every 10 primiparous women with spontaneous deliveries received an episiotomy. If this figure is applied to the 2.35 million primiparous Latin Americans who give birth each year, then 2.17 million will receive an
episiotomy. This situation, the authors say, is inadmissible in light
of current evidence, and this overuse of episiotomy needs to change.
Basic training in cognitive behaviour therapy is not effective
King and colleagues (p 947) show that basic training in brief cognitive
behaviour therapy, comprising four half days, has little effect on
general practitioners' treatment or attitude towards identification of
depression, nor does it affect the outcome of their patients with
emotional problems. Although there is evidence that cognitive behaviour
therapy is effective in treating depression, the authors say that to
have a positive impact on their patients, general practitioners would
require more extensive training.
(Credit: ANTONIA REEVE/SPL)
Australian GPs overestimate their knowledge of evidence based concepts
Self rating of general practitioners' understanding of terms
used in evidence based medicine
for example, relative risk or sensitivitydoes not match up to the objective measurement of knowledge. Young and colleagues (p 950) sent 50 Sydney general practitioners a questionnaire survey in which they rated their understanding of seven terms commonly used in evidence based medicine. They were then asked to explain the terms to a medical student. Although self ratings were modest, participants' verbal explanations almost never matched their self rating, and no participant showed competence that exceeded their self rating.
Academic record predicts success at medical school
A systematic review of the literature shows that previous academic
performance is a good predictor of achievement at medical school.
Ferguson and colleagues (p 952) say, however, that the correlation is
not perfect and previous academic performance accounts for 23% of
variance in performance in undergraduate medical training and 6% of
that in postgraduate training. Little research has been done into the
importance of learning styles, ethnicity, and sex differences, but a
strategic learning style, white ethnicity, and being female are
associated with success in medical training.
Lack of acute beds overcrowds emergency departments
Overcrowding in the emergency department is the biggest impediment to
the delivery of care, says Fatovich (p 958) in this week's clinical
review. The main cause is that the inflow into departments is greater
than the outflow as patients are denied access to ongoing care owing to
bed shortages. This is termed "access block." Departments, he
warns, may no longer be able to supply emergency care that is both
timely and of a high quality.
(Credit: LETTAU/ARNOLD INC/SPL)
Regulation in the NHS: is it good news?
The recent creation of five national agencies to regulate the NHS could
be the start of a genuinely new approach to improving performance and
management in the NHS. If politicians can be persuaded to let go, the
new agencies could learn from regulators in other sectors, says
Walshe (p 967), and they could focus regulation on delivering real
improvement for patients.
When should transplants not be performed?
A candidate for limb allografts should be somebody who could gain the
most and for whom the associated risks are lowest, say Benatar and
Hudson (p 971). They discuss two cases in which surgeons decided not to
perform limb allograftsone in a boy of 3 with no hands, the other a
girl of 4 with no hands or feet. Costs to health and cumulative
lifetime risks of immunosuppression are substantial and do not always
outweigh functional benefits.
(Credit: JV2/SPL)
