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US
editor’s choice
November 25
It’s Thanksgiving this week,
which means feasting for many in the United States. In an (un)timely
reminder of the association between lifestyle and disease, this week’s
BMJ carries various articles on heart disease.
Predicting the risk of death
or myocardial infarction in patients with acute coronary syndrome is
challenging because of the diverse clinical presentations. To guide triage
and key management decisions, however, risk assessment is essential. Fox and
colleagues report a prospective multinational observational
study of 43
810 patients in 94 hospitals in 14 countries in Europe, North and South
America, Australia, and New Zealand. They developed a new and widely
applicable tool, the global registry of acute coronary events (GRACE)
scoring system, using nine readily identifiable variables that independently
predict death or myocardial infarction. Junghans and Timmis in the
accompanying
editorial balance the advantages against the disadvantages and come out
wondering whether this new scoring system is really so very different from
other attempts at refining the process of risk assessment—or whether what’s
really needed is a closer look at why risk assessment in general is so
difficult to adopt in clinical practice.
More on matters of the heart:
in the analysis and comment section, Wald and colleagues
debate the
evidence from various types of study on a possible association of raised
homocysteine concentrations and cardiovascular disease and on whether folic
acid, which lowers homocysteine, will help reduce the risk. They take the
view that, although the evidence is not conclusive, it is sufficient to
support a modest protective effect of folic acid, but encourage continuing
review of this position in the light of new evidence.
Prostate cancer is common and
potentially serious, especially as most men with the disease have no
symptoms. Few established risk prevention strategies exist, and testing has
a poor positive predictive value. How, then to tackle a disease that in 2002
alone was diagnosed in 32 000 men in the United Kingdom, with more than
10 000 deaths attributed to it? US authors Timothy Wilt and Ian
Thompson in a comprehensive
clinical review
discuss the evidence on risk factors and prevention, detection, and
treatment, to help family doctors answer patients’ questions, capture
ongoing research priorities, and clarify unanswered questions. All this in
an interesting and readable article that may appeal to educated patients and
doctors alike.
This week's US Highlights were compiled by
Birte Twisselmann, assistant editor (web).
November 18
In a new analysis of the
saline versus albumin fluid evaluation (SAFE) study, the
investigators
examined clinical outcomes of over 6000 Australian
patients in intensive care who had been
randomized to receive either saline or albumin for their fluid
resuscitation. Whether their initial serum albumin levels were high or low,
there was no difference in mortality, length of stay, or other outcome
variables between the two groups. In an accompanying
editorial, J
L Vincent points out that the SAFE study was undertaken to establish not
whether albumin was better than saline, but whether it was as safe, which it
was. He argues that no one would use albumin for all patients needing fluids
and advocates a trial comparing albumin and saline in ICU patients who are
at increased risk of complications.
Can
increased physical activity reduce weight in preschool children? John Reilly
et al performed a randomized controlled
trial in 36
Scottish preschools with 545 children. Half the schools received a physical
activity intervention consisting of three 30 minute physical education
classes, classroom posters, and home resource packs. The other half served
as controls. At six and 12 months, there was no difference between the BMI
scores in the two groups of children, although the intervention group
children had better movement skills. Antronette Yancey writes in an
editorial
that this result is unsurprising given the “dose” of the intervention and
the fact that it was probably applied inconsistently in real world settings.
Correct implementation of programs, as well as increased comprehensiveness,
are probably needed to show a change in children’s weights.
Finally,
this week’s issue has an
ethical debate
about whether it can ever be ethical to withhold prenatal testing. The case
in point involves a fetus at risk for the gene for Huntington’s disease,
which is detectable in utero. The disease is universally fatal but does not
appear until young adulthood. Some ethical guidelines call for providing
prenatal diagnosis only if the parents are planning to abort a fetus that is
found to be affected. Martin Delatycki argues that it is appropriate
to withhold the test if the parents are not planning an abortion on the
grounds of autonomy—otherwise they will be denying their future child the
right to determine when and if he learns his diagnosis. Rony Duncan and
Bennett Foddy disagree,
citing several arguments: in the first trimester, the fetus is part of the
mother’s body and she should not be denied knowledge about her own body; a
couple can never “know” with 100% certainty whether or not they will abort a
fetus; and no one should be placed in the untenable position of having to
lie to obtain a medical diagnostic test. As genetic medicine becomes more
widespread, dilemmas such as this will likely increase.
November 11
Should we be screening our
service men and women for mental disorders and alcoholism before they go
into combat? Roberto Rona et al performed a
follow-up study of 1885 members of the British armed forces who had
completed a battery of mental health tests before the current Gulf war. They
found correlations between the first and second round survey results, but
the first tests did not predict important outcomes such as post-traumatic
stress disorder or alcoholism. In a related
editorial US Veterans Affairs consultant Kenneth Hyams points out that
recruitment and training standards have increased considerably in modern
armed forces and that it is unlikely that pre-deployment testing will
identify many soldiers who will later develop mental health problems.
There are multiple ways
to manage knee pain; in the US and UK we generally focus on treatment by
primary care or specialist doctors. Elaine Hay and colleagues compared the
effectiveness of community physical therapy sessions, pharmacist
consultation, and usual care in a randomized controlled
trial of about 300 elderly British patients with knee pain. After three
months, the patients in the physical therapy and pharmacist groups had
significantly improved pain control, function, and satisfaction as well as
decreased pain medicine use. These improvements were not sustained at six
and 12 month follow-ups, however.
Carmel Hughes and Chris Bleakley suggest that the fall-off in improvement
could have been due lack of continuing adherence to treatment, which wasn’t
well measured in the study. In an
editorial they suggest that the respective interventions might have been
effective for a longer period if they were increased in “dosage” or
combined.
Observational studies have found a protective effect of statin drugs in
patients who develop serious infections such as pneumonia. To test this
finding Sumit Majumdar and associates
studied
a cohort of 3415 Canadians admitted to hospitals with pneumonia.
After adjusting for the fact that statin users tend to be healthier, they
found no significant effect of pre-existing or concurrent statin use on
mortality or intensive care unit admission rates. Reimar Thomsen discusses
this “healthy user” effect in an
editorial and cautions that it is often a problem in large-scale
observational studies that report unexpected positive results.
November 4
Tennis elbow, or lateral
humeral epicondylitis, is an overuse syndrome seen commonly in primary care.
Most agree that steroid injections help, but little standardized research has
been done on the condition. Leanne
Bisset et al performed a randomized controlled
trial in 198 community residents with tennis elbow, comparing one or two
steroid injections, eight weekly physical therapy sessions, and a wait and
see approach (which included advice on rest, analgesics, and bracing). They
found a short term benefit of steroid injections that reversed after the
first six weeks. At one year, the two non-injection alternatives had better
outcomes. In an accompanying
editorial, Nynke Smidt and Danielle van der Windt point out that other
trials have also reported poor long term results for steroid injections.
This could be due to steroid induced weakening of tendons (less likely) or
to overuse because of rapid recovery leading to reinjury. For most patients,
a long term “wait and see” policy may be most appropriate.
Are
breast-fed children smarter? Yes, say many studies, but Geoff Der and
colleagues use three different types of
analyses—a prospective study of a US national database, a comparison of
siblings from the same database, and a meta-analysis—to establish that the
reason breastfed babies have higher IQs is that their mothers are smarter.
Sandra Jacobson and Joseph Jacobson comment in an
editorial that controlling for maternal IQ is crucial. There are plenty
of good reasons that women should breast feed their babies, but increasing
their child’s intelligence apparently isn’t one of them.
Finally,
for over 30 years, Swan-Ganz (pulmonary artery) catheterization has been
part of the standard of care in the management of critically ill patients. In an
editorial, Simon Finfer and Anthony Delaney briefly review the evidence
that these expensive devices actually help patients. A recent UK health
technology assessment has reported that five large randomized controlled
trials all failed to show any clinical benefit of pulmonary artery
catheters. An accompanying economic analysis concludes that if use of these
catheters were discontinued, there would be a net mortality benefit at a
rather modest cost. It seems now that proponents of using pulmonary artery
catheters need to show that these devices’ known risks are outweighed by
their as yet unproven benefits.
October 28
Patients’
self management is touted as an important adjunct to medical care for
chronic diseases, and some studies have shown that self-management training
can improve clinical outcomes. Marta Buszewicz and colleagues performed a
randomized controlled
trial of 812 UK general practice patients with arthritis, comparing the
effectiveness of a six session self management course with receipt of an
educational booklet. After 12 months, the trained group had significantly
less anxiety and perceived self efficacy, but there were no differences in
arthritis pain, physical functioning, or number of GP visits. In a related
editorial, Peter Croft and Elaine Hay point out that other self
management studies, though admittedly of volunteers, have found more
positive results. Despite it being common sense and good patient care to
inform patients about their disease, the Buszewicz study calls into question
whether self management courses for patients with chronic diseases are worth
the time and expense.
Can
effective psychotherapy be delivered over the telephone? Karina Lovell et al
randomized 70 patients with obsessive compulsive disorder to receive 10
weekly cognitive behavior therapy sessions either in person on by phone.
They found that patients receiving the phone sessions had outcomes that were
no worse than those with face to face therapy. Such telephone talk therapy
might be especially useful in rural or other underserved settings.
Influenza
season is upon us, and with it the exhortations of public health authorities
to vaccinate everyone but healthy young adults. Tom Jefferson
analyzes the evidence for the effectiveness of flu shots and finds it
surprisingly thin. Because circulating influenza antigens change every year,
research is difficult to do. Systematic reviews of the research contain
little convincing evidence of the effectiveness of flu vaccine. Many
published studies have methodological problems. Jefferson urges
re-evaluation of the worth of national influenza immunization campaigns.
Finally,
just before the November 7 elections, South Dakota obstetrician-gynecologist
Marvin Buehner describes his
personal view of the effects of a recently passed state anti-abortion
law that is up for recall. The law, which outlawed all abortions except
those performed to avert a woman’s death, has led to a strong grass-roots
campaign to repeal it. Buehner provides examples of what he calls the
“environment of intimidation” of doctors that anti-abortion groups have
created in South Dakota.
October 21
This week’s theme issue of the BMJ is
devoted to health in the Middle East—as Wasim Maziak puts it in the opening
editorial, “No one’s
priority, everyone’s problem.” The author vividly evokes a region that has
gone from one of the most advanced civilisations in its time, where the
foundations of modern medicine were laid, to a region fighting with the
legacy of past conflicts and externally imposed boundaries, which includes
“some of the poorest and some of he richest countries in the world, whose
basic health indicators generally parallel their economic status.” Such vast
economic and health discrepancies present equally vast challenges, and the
fact that governments have not provided comprehensive health services has
led to health care being taken over by market forces. Which, in turn,
contributes to ever increasing social differentials.
The fact that spending on defence is hugely
higher than spending on health is another problem. So, what is to be done to
improve the situation for the more than half a billion people in the region?
International action is important—and international interest is reflected in
the number of US (and European) co-authors to the issue—but so are community
based interventions. Zulfiqar Bhutta and colleagues
argue that improving health in the region depends not only on
resources but also on political will and social determinants.
These include not least increased freedom and
choice—and better sexual and reproductive health services—for women and
young people, as Jocelyn DeJong and Golda El-Khoury
point out. HIV and AIDS present a particular challenge in the
region, whose prevalence is thus far low but may not remain so, as Obermeyer
poignantly
explains. And Alex Leventhal and colleagues
report how successful collaboration in the region contained
outbreaks of H5N1 avian flu and may help create an infrastructure for cross
border collaboration in emergencies such as outbreaks of infection.
This week's US Highlights were compiled by
Birte Twisselmann, assistant editor (web).
Archive of US Highlights
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November 25
Risk
assessment after acute coronary syndrome
Cornelia Junghans, Adam D
Timmins
Prediction of
risk of death and myocardial infarction in the six months after
presentation with acute coronary syndrome: prospective multinational
observational study
Keith A A Fox et al
Clinically
localised prostate cancer
Timothy J Wilt, Ian M
Thompson
Folic acid,
homocysteine, and cardiovascular disease: judging causality in the face
of inconclusive trial evidence
David S Wald et al
November 18
Resuscitation
using albumin in critically ill patients
J L
Vincent
Tackling
childhood obesity
Antronette Yancey
Physical
activity to prevent obesity in young children: cluster randomised
controlled trial
John J
Reilly et al
Effect of
baseline serum albumin concentration on outcome of resuscitation with
albumin or saline in patients in intensive care units: analysis of data
from the saline versus albumin fluid evaluation (SAFE) study
Saline
versus Albumin Fluid Evaluation Study Investigators
Refusing to
provide a prenatal test: can it ever be ethical?
Rony E Duncan et al
November 11
Mental health screening before troop
deployment
Kenneth
Craig Hyams
The lesser known effects of statins
Reimar W
Thomsen
Treatment of knee pain in primary care
Carmel M
Hughes, Chris M Bleakley
Mental health screening in armed forces before the Iraq
war and prevention of subsequent psychological morbidity: follow-up study
Roberto
J Rona et al
Effectiveness of community physiotherapy
and enhanced pharmacy review for knee pain in people aged over 55
presenting to primary care: pragmatic randomised trial
Elaine M
Hay et al
Statins and outcomes in patients admitted
to hospital with community acquired pneumonia: population based
prospective cohort study
Sumit R
Majumdar et al
November 4
Tennis elbow in primary care
Nynke
Smidt, Danielle AWM van der Windt
Breast feeding and intelligence in children
Sandra W
Jacobson, Joseph L Jacobson
Pulmonary artery catheters
Simon
Finfer, Anthony Delaney
Mobilisation with movement and exercise,
corticosteroid injection, or wait and see for tennis elbow: randomised
trial
Leanne
Bisset et al
Effect of breast feeding on intelligence in
children: prospective study, sibling pairs analysis, and meta-analysis
Geoff
Der et al
October 28
Osteoarthritis in primary care
Peter
Croft, Elaine Hay
Self management of arthritis in primary care: randomised controlled trial
Marta
Buszewicz et al
Telephone administered cognitive behaviour therapy for treatment of
obsessive compulsive disorder: randomised controlled non-inferiority
trial
Karina
Lovell et al
Influenza vaccination: policy versus evidence
Tom
Jefferson
Why this abortion ban is a threat to women’s health
Marvin
Buehner
October 21
Health in the Middle East
Wasim Maziak
Child Health and survival in the Eastern
Mediterranean region
Zulfiqar A Bhutta et al
Reproductive health of Arab young people
Jocelyn DeJong, Golda El-Khouri
HIV in the Middle East
Carla Makhlouf Obermeyer
Regional collaboration in the Middle East
to deal with H5N1 avian flu
Alex Leventhal et al
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