This week in the BMJ

Volume 327, Number 7405, Issue of 5 Jul 2003

Risk stratified rates better than surgeon specific mortality data
Risk of liver injury from NSAIDs is small
Respiratory vaccine for infants is still a long way off
Prehospital thrombolysis by paramedics saves time
Effectiveness of nicotine patches is overstated
Complications of mastoiditis are rare but life threatening
Knowledge translation helps close a gap

Risk stratified rates better than surgeon specific mortality data

Crude comparisons of surgeon specific death rates can be misleading,and release of such information into the public domain mayencourage surgeons to practise risk averse behaviour. Bridgewaterand colleagues (p 13) analysed data for 8572 patients whohad had isolated bypass graft surgery for the first time during1999-2002 in the north west of England. They found that mostof the predicted variability in death rates among surgeonswas due to a small but differing number of high risk patients.The authors recommend a comparison of death rates that is stratifiedby risk and based on low risk cases as the national benchmarkfor assessing consultant specific performance.

Credit: ANTONIA REEVE/SPL

Risk of liver injury from NSAIDs is small

The risk of hepatotoxicity associated with non-steroidal anti-inflammatory drugs, including nimesulide, is small. A five year retrospectivecohort study by Traversa and colleagues looked at almost 2million prescriptions in the Umbria region of Italy (p 18).It found no significant increase in risk when the incidenceof hepatopathy among users of nimesulide was compared withother non-steroidal anti-inflammatory drugs. Nimesulide hasbeen withdrawn from use in Finland and Spain because of reportedincreases in liver injury.

Respiratory vaccine for infants is still a long way off

Viral infections of the lower respiratory tract impose a considerable burden on healthcare budgets. Van Wonsel and colleagues (p 36)review their epidemiology, symptoms, and treatment in infectionsin young children. They conclude that viral lower respiratorytract infections are mild and self limiting in most cases,and that treatment is mainly supportive, but varies widelyworldwide. Apart from influenza vaccine, research into vaccinationhas mainly focused on respiratory syncytial virus. Althoughprogress has been made, particularly with live attenuated vaccines,it will be another decade before routine vaccination is available.

Prehospital thrombolysis by paramedics saves time

Early thrombolysis for acute myocardial infarction has beenshown unequivocally to improve outcome, but the current nationaltarget of delivery of thrombolysis in less than 60 minutesis difficult to meet in rural areas. Pedley and colleagues(p 22) report on a system of prehospital thrombolysis deliveredby paramedics, with remote decision support provided by thelocal accident and emergency department using a mobile telemetrylink. This resulted in a reduction in median call to needletime for rural patients of 73 minutes compared with a similargroup of patients treated in the conventional manner. In anotherpaper this week, Keeling and colleagues (p 27) report that autonomous prehospital thrombolysis can be effectively and safelyadministered by paramedics. Their feasibility study showedan average time saving of 48 minutes from the call to drug administration.

Effectiveness of nicotine patches is overstated

Former smokers using nicotine patches often return to smoking.In an eight year follow up of people who took part in a randomisedtrial of the patch, Yudkin and colleagues (p 28) report thatnearly half of those who had given up smoking for a year inthe original trial had taken it up again, and that relapse rateswere similar in nicotine patch and placebo groups. The costeffectiveness of nicotine replacement therapy is thereforeoverestimated when it is based on relatively short term results.Of all trial entrants, 88% were smoking eight years later,underlining the difficulty that smokers have in giving up.

Credit: SIPA/REX

Complications of mastoiditis are rare but life threatening

Partially treated mastoiditis can mask the classic symptomsof intracranial and extracranial complications. Jose and colleagues (p 41) report two cases of lateral sinus thrombosis and a caseof Bezold's abscess, which emphasise the importance of a highindex of suspicion in patients with ear infections that failto respond predictably. The authors say that magnetic resonanceimaging is better than computed tomography in identifying intracranialcomplications.

Knowledge translation helps close a gap

When education and persuasion of doctors cannot close the gapbetween evidence and practice, "knowledge translation" may— by including groups other than doctors and investigatingissues more comprehensively than the educational strategiesof CME and CPD. This system of exchange, synthesis, and ethicallysound application of knowledge can capture the benefits ofresearch, say Davis and colleagues (p 33). They present amodel containing interventions that might be effective at variousstages of the change process, which could promote the rapiduptake of evidence based knowledge.