US Highlights

Here are items from recent BMJ issues that may be of particular interest to American readers. Happy reading. Comments welcome.

Douglas Kamerow
US editor

US editor’s choice

April 29

Everyone agrees major depression is common, serious, and treatable. The question is whether we should screen for it in primary care. The respected US Preventive Services Task Force said yes in 2002, if systems are in place to treat identified patients. Simon Gilbody and colleagues evaluated the evidence on depression screening against criteria from the UK National Screening Committee and recommend against routine screening. They argue, with data from their recent Cochrane review, that the screening tests may not be acceptable to doctors and patients, clinical management of depressed patients is not optimized in primary care, high quality randomized trials have not established that screening (alone) improves morbidity, and it is not clear that these programs are cost effective. In an accompanying editorial, Jan Scott argues that depression should be treated like a chronic, relapsing disease. Effective disease management programs should be put in place to identify and manage depression in primary care among high risk patients, as is done for medical conditions such as asthma and congestive heart failure. It’s an important debate.

J Meirion Thomas and Victoria Giblin discuss prevention and early detection of melanoma in an editorial that advocates primary prevention and early diagnosis. Unfortunately, national education campaigns to prevent childhood sunburns and thus reduce melanoma risk haven’t worked well in the US and Europe, and early diagnosis is often difficult even when the doctor finds a lesion.

Not much research has been published about the effect of a parent’s cancer on his or her children. Gillian Forrest and associates conducted a qualitative study of children of women with breast cancer, interviewing 37 mothers and 31 of their children. They found that most children didn’t think they had been told enough about the cancer despite the fact that most mothers thought they had shared a good amount of information; that many children suspected something was wrong before they were told of their mother’s breast cancer; and that many children needed more preparation and information about cancer, perhaps from clinicians or websites.

Keyur Patel et al review the diagnosis and treatment of hepatitis C, an increasingly common problem that progresses to a chronic infection in up to 85% of patients. It is commonly transmitted by injecting drug use or transfusion of infected blood. Acute infection is usually subclinical, but end stage liver disease eventually occurs in up to 20% of patients. Treatment with interferon alfa and ribavirin can help about half the patients who receive them.
 

April 22

Eczema or atopic dermatitis is a common and occasionally debilitating disorder in children. Treatment effectiveness has not been well studied. Doris Staab and associates performed a randomized controlled trial comparing age appropriate educational programs for three different groups of children and adolescents. They found significant long term improvement in each group, compared with controls, in subjective and objective measurements of disease and in quality of life. In a commentary, Peter Lapsley points out that the benefits of the educational program are both to patients and to busy general practitioners. While praising the study in the accompanying editorial, Hywel Williams argues that only proved therapies should be taught in eczema classes and that economic analyses still need to be done.

The internet is changing everything, including medical care. It is common for doctors to warn their patients that it is a jungle out there and to beware of health information in cyberspace. In one of the first studies of the accuracy of the list serves for patients that have become so popular, Adol Esquivel et al assessed 4600 postings to a breast cancer list serve. They found that only 10 had false or misleading information. Six of the 10 postings were corrected by other list members within hours. Alejandro Jadad and others put these online communities in perspective and state that it is not surprising that they self organize as well as they do. Although more research needs to be done, this study gives data (and hope) that patients can rely on such tools with some confidence.

Finally, two clinical pearls from case reports to close out the issue: atorvastatin (and presumably other statins) can cause nightmares, and timolol eye drops may lead to syncope and falls.
 

April 15

Using a cell phone neither increases your risk of a brain tumour in the short or medium term, nor does it cause worse headaches in “sensitive” people, as two recent studies have shown. In the UK part of an international study, Hepworth and colleagues conducted a case-control study among almost 100 patients with a glioma and found no relation for risk of glioma and time since first use, lifetime years of use, cumulative hours of use, or cumulative numbers of calls. In a separate study in London, UK, Rubin and colleagues conducted a double blind randomized study comparing 60 people with self reported headaches within 20 minutes after using a cell phone with 60 people who did not report such symptoms. In a provocation test they exposed participants to three "conditions." They found that people who reported sensitivity to mobile phone signals cannot detect such signals and are no more likely to have worse headaches than people who are not sensitive. The authors propose that self reported sensitivity to cell phone signals may be primarily psychological. And Maier, in an accompanying editorial concludes that the biggest risk posed by cell phones is using them while driving. So it’s official: it’s still good to talk

Systemic lupus erythematosus was once considered a rare disease with a fatal outcome. The past 20 years have shown that the disease is common as well as treatable. D’Cruz in his clinical review emphasizes the importance of early diagnosis and discusses available drug treatments. Improving patients’ quality of life and minimizing cardiovascular risks are among the remaining challenges.

Finally, journalist Jeanne Lenzer reviews reports how a media watchdog in Madison, Wisconsin, revealed how US television networks are broadcasting pharmaceutical promotions disguised as “news”. The Center for Media and Democracy recently issued a report that tracked the use of 36 video news releases (VNRs) aired by news outlets over the past 10 months. VNRs are designed to look like independently produced news but are actually prepackaged promotions containing film footage created by corporate publicists or their public relations firms.

Compiled by Birte Twisselmann
 

April 8

This week’s issue is especially strong in research and reviews on child health.  

Screening young children for amblyopia (often called “lazy eye”) is controversial. Tales of permanent deficits in undiagnosed eyes and lifetime poor vision have been used to justify population screening recommendations. J S Rahi and colleagues compared  429 people with unilateral childhood amblyopia who were followed for more than 40 years with 8432 people with two normal eyes. No functional differences were found along a range of characteristics, including educational, social, and occupational outcomes. These findings make it hard to justify screening and treating children for amblyopia.  

MDMA, or ecstasy, is a psychoactive drug that is widely used by young people in Europe and the US. One theory behind its popularity is that users are “self medicating” their pre-existing depression or anxiety, but it is notoriously difficult to prove such causal relations. Anja Huizink and colleagues followed a population of Dutch youth who were first evaluated at a time before ecstasy was available. They found a significantly increased risk of ecstasy use in those who had symptoms of depression or anxiety at baseline. In an accompanying editorial, Kari Poikolainen points out that drug use rarely has only one risk factor and that only 10% of those with psychological symptoms used ecstasy. But it does seem that depressed and anxious adolescents were at increased risk for drug abuse.

Finally, for all of us with adolescent patients (or children!) who go to bed too late and get up too early, Suresh Kotagal and Paul Pianosi review childhood sleep disorders. The good news is that by far the most common reason for zombie-like, sleep deprived adolescent behavior is poor sleep hygiene. The authors offer several recommendations for improving sleep hygiene in teenagers, including going to bed only when sleepy, decreasing stimulation—physical and mental—in the evenings, and avoiding caffeine and nicotine. They also review more serious and much less common causes of sleep problems in this age group.

Institutionalized adults with dementia often receive major tranquilizers to control their behavior, despite questionable evidence of efficacy and common, often major, side effects. Jane Fossey et al randomized 12 British nursing homes to receive either staff training on alternative, “person-centered” ways to manage behavioral problems in demented patients or no intervention. After one year, significantly fewer patients in the intervention nursing homes were receiving neuroleptic drugs than in the control homes. Gavin Andrews comments on both the difficulty and importance of extending this work with further research, so that ultimately, through guidelines and practice standards, it can be applied universally.

April 1

Omega 3 fatty acids are necessary for brain cell growth and are a widely recommended (and taken) supplement. Clinical trials have shown benefits in patients with coronary heart disease. Lee Hooper and colleagues performed a systematic review  of the risks and benefits of omega 3 fats for mortality, cardiovascular disease, and cancer in all types of patients and found no consistent benefits. They recommend caution in universal recommendations for omega 3 supplementation. In an accompanying editorial, Eric Brunner discusses the possible pro-arrhythmic effects of these fats, especially when taken as capsules rather than by eating oily fish. He also points out that another claimed benefit of omega 3 fats is prevention of cognitive impairment and dementia, which is not addressed by this review and is the subject of ongoing research.

Phyllis Carr and Kenneth Edelin of Boston University describe a longstanding program in their institution for increasing the number of medical students from under-represented minorities. They argue that it should be replicated around the US if we are to address in a meaningful way racial disparities both in the physician workforce and in population health. Their initiative has similar goals to a summer school program in London for 16 year olds from economically deprived and under-represented ethnic minority groups reported by Trisha Greenhalgh and associates.

Institutionalized adults with dementia often receive major tranquilizers to control their behavior, despite questionable evidence of efficacy and common, often major, side effects. Jane Fossey et al randomized 12 British nursing homes to receive either staff training on alternative, “person-centered” ways to manage behavioral problems in demented patients or no intervention. After one year, significantly fewer patients in the intervention nursing homes were receiving neuroleptic drugs than in the control homes. Gavin Andrews comments on both the difficulty and importance of extending this work with further research, so that ultimately, through guidelines and practice standards, it can be applied universally.

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