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

May 27

Doctors usually groan when, as they stand up to leave the examination room and reach for the door knob, the patient says, “One more thing, doctor” and proceeds to raise an important symptom or concern. Embarrassing or frightening concerns are often mentioned late in the encounter or not at all. J F Middleton and colleagues performed a randomized controlled trial of giving agenda forms to patients and educating doctors to ask about the patient’s agenda for the visit at the outset. They found that these interventions increased the number of problems identified, at the cost of a longer encounter. William Hamilton and Nicky Britten comment in a related editorial that we really don’t know the importance of the additional items raised and whether the forms and/or training resulted in increased long term efficiency and effectiveness of care. Perhaps a study Hamilton and Britten are doing on the topic will shed more light on this important area. 

We have known for a while that increased alcohol consumption correlates with decreased coronary heart disease (CHD) on a population basis. A large Danish cohort study performed by Janne Tolstrup et al additionally finds that, in men, the most important factor seems to be the frequency of alcohol intake. That is, men who drink daily, regardless of their total intake, have the lowest risk of CHD. Surprisingly, this is not the case with women, in whom total alcohol intake is a more important factor than frequency. The authors and editorialist Annie Britton struggle to explain these findings. Britton points out that the response rate of the study was only 35%, which means that many drinkers, presumably at the extremes of intake, excluded themselves. This study will no doubt get a large amount of publicity, and doctors should be ready to respond to patients’ queries about it.

Finally, Wisam Al-Hakim and colleagues remind us that orthopedic surgeons have much to offer terminal cancer patients with bone pain or functional compromise. Palliative surgery can often make an important difference in the quality of life of these patients.

20 May

To what extent ethnicity is an important contributor to the variable outcome of drug treatment remains a matter of debate. Sarah McDowell and colleagues conducted a systematic review and meta-analysis of 564 studies that included at least two ethnic groups and one or more adverse drug reactions. They found that patients from different ethnic groups have different risks for adverse reactions to cardiovascular drugs. Ethnic group may act as a marker for underlying genetic differences or cultural factors that influence the risk. The authors conclude that data are too sparse, and regulators should consider asking for better data before licensing. In an accompanying editorial, Erik Eliasson argues that although “personalised” drug treatment may be an option in the not too far future, this will be no substitute for increased awareness of such adverse reactions and good clinical judgment on the part of clinicians, to enable more accurate risk assessment.

Getting patients to adopt healthier behaviour can be an uphill struggle. Using techniques of “social marketing” to influence consumers may be one way to improve success. W Douglas Evans explains how commercial marketing strategies—such as audience segmentation and branding—can be applied in health care and are effective at a population level. Gerard Hastings and Laura McDermott examine strategies in practice and explain why understanding the needs and views of patients is at the heart of this approach.

After the steady news feeds about the perceived danger of avian influenza, here comes the Hollywood treatment. Fatal Contact: Bird Flu in America, a television movie aired in the US on 9 May, painted a worst case scenario of a fictitious global bird flu pandemic. Doug Kamerow, in a thoughtful review, concludes that in spite of some scientific inaccuracies, the story was grippingly told and visually effective. Most of all, it was entertaining and got people thinking—whether this could really happen and what we would do about it.

Compiled by Birte Twisselmann, assistant editor (web)

May 13

Human papillomavirus vaccine is about to be approved in the US. It is controversial because it works to decrease risk for cervical cancer by preventing a sexually transmitted disease. It thus must be delivered before sexual activity begins, which in the US means early adolescence. Ethicist and internist Bernard Lo discusses some of the issues around this new vaccine in an editorial. HPV vaccine is unlike most immunizations because it is targeted at a condition—cervical cancer acquired through HPV infection—that is not transmissible except through sexual intercourse. Both parents and their adolescent daughters will need to give consent for the vaccine to be administered.

Patients with diabetes who have not had a myocardial infarction have the same risk of MI as non-diabetics who have already had one. This general finding has led to recommendations that all diabetics be placed on lipid lowering drugs. João Costa and colleagues systematically reviewed the trials of lipid lowering and risk of heart disease and performed a meta-analysis comparing patients with and without diabetes. They confirmed that lipid lowering, especially with statin drugs, leads to a 21% reduction in the risk of cardiovascular events in patients with diabetes. In an accompanying editorial, John Reckless agrees and recommends that most diabetic patients with an LDL cholesterol measurement greater than 80 mg/dl be started on statins.

Prevention and treatment of dementia, whether caused by vascular disease or the Alzheimer’s type, is a big problem. The role of cerebral emboli as a causative factor in dementia has not been well defined. Nitin Purandare et al used transcranial Doppler to compare patients with Alzheimer’s and vascular dementia with matched controls. More than one third of patients with either type of dementia had spontaneous cerebral emboli, significantly more than the controls. Miia Kivipelto and Alina Solomon comment in an editorial that this is a cross-sectional study that cannot prove etiology. However, it does give hope that some dementias of both neurodegenerative and vascular types—which may not be all that different—can be prevented or postponed by early aggressive treatment of vascular risk factors.

May 6

Inhaled insulin is now available in the US, although it costs more than the standard subcutaneous formulations. In an informative editorial, Emma Morton-Eggleston and Eugene Barrett describe the properties and likely utility of this breakthrough product. It works a lot like regular insulin: fast acting and fast to disappear. Because of that, it will not replace the long-term injectable preparations, but it may be very useful as an adjunct to oral agents for patients with type 2 diabetes.

Thomas Houston and colleagues report yet another reason patients shouldn’t smoke cigarettes: increased risk of glucose intolerance. They followed over 4500 black and white American young adults for 15 years and found an increasing risk of developing glucose intolerance related to exposure to tobacco smoke, including a history of passive exposure. Thus, after adjusting for other risk factors, current smokers had a greater risk of glucose intolerance than former smokers, who had a greater risk than those passively exposed to tobacco smoke. The least risk was among those with no tobacco smoke exposure. In an accompanying editorial, Demosthenes Panagiotakos and Christos Pitsavos praise the large sample size of the study but caution that residual confounding due to confounding risk factors still may exist.

Community-acquired pneumonia is a common and important cause of morbidity and mortality. Zara Hoare and Wei Shen Lim review the diagnosis and management of pneumonia, focusing on using a scoring system such as the CURB-65 to identify severe pneumonia. Herman Goossens and Paul Little ask in an editorial how best to determine the pathogen causing—and thus the appropriate antibiotic for—lower respiratory tract infections. This is important for individual patient care and also to slow the growth of antibiotic resistance in the community. The bad news is that microbiologic techniques have not advanced much for a hundred years and newer serologic and genomic tests are not ready for prime time in primary care.

A final contribution worth noting tested the age-old wisdom that sutured wounds should be kept dry initially to prevent infection. Clare Heal and colleagues compared usual care of minor excisions in general practice with allowing wounds to be uncovered and wet in the first 48 hours after suturing. There was no difference in infection rates.

May 6

Inhaled insulin is now available in the US, although it costs more than the standard subcutaneous formulations. In an informative editorial, Emma Morton-Eggleston and Eugene Barrett describe the properties and likely utility of this breakthrough product. It works a lot like regular insulin: fast acting and fast to disappear. Because of that, it will not replace the long-term injectable preparations, but it may be very useful as an adjunct to oral agents for patients with type 2 diabetes.

Thomas Houston and colleagues report yet another reason patients shouldn’t smoke cigarettes: increased risk of glucose intolerance. They followed over 4500 black and white American young adults for 15 years and found an increasing risk of developing glucose intolerance related to exposure to tobacco smoke, including a history of passive exposure. Thus, after adjusting for other risk factors, current smokers had a greater risk of glucose intolerance than former smokers, who had a greater risk than those passively exposed to tobacco smoke. The least risk was among those with no tobacco smoke exposure. In an accompanying editorial, Demosthenes Panagiotakos and Christos Pitsavos praise the large sample size of the study but caution that residual confounding due to confounding risk factors still may exist.

Community-acquired pneumonia is a common and important cause of morbidity and mortality. Zara Hoare and Wei Shen Lim review the diagnosis and management of pneumonia, focusing on using a scoring system such as the CURB-65 to identify severe pneumonia. Herman Goossens and Paul Little ask in an editorial how best to determine the pathogen causing—and thus the appropriate antibiotic for—lower respiratory tract infections. This is important for individual patient care and also to slow the growth of antibiotic resistance in the community. The bad news is that microbiologic techniques have not advanced much for a hundred years and newer serologic and genomic tests are not ready for prime time in primary care.

A final contribution worth noting tested the age-old wisdom that sutured wounds should be kept dry initially to prevent infection. Clare Heal and colleagues compared usual care of minor excisions in general practice with allowing wounds to be uncovered and wet in the first 48 hours after suturing. There was no difference in infection rates.