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US
editor’s choice
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).
October 14
We are
always telling our children and young patients to drink their milk so that
they will build strong bones, but does calcium supplementation really do
that in a meaningful way? Tania Winzenberg and colleagues evaluated 19
studies of calcium supplementation in childhood in a
meta-analysis. They found that calcium led to a slight
statistical increase in bone mineral density but nothing clinically
significant. In an accompanying
editorial, Amy Lanou points out that exercise is a proven
stimulant to bone density but dietary calcium is not. She recommends a focus
on weight-bearing exercise for kids and a revision of child and adolescent
calcium intake guidelines.
We can
prevent diabetes by getting at-risk patients to lose weight, but that is
hard to do and harder to maintain. Giving pills is easy, and Carl Heneghan
et al
discuss the pros and cons of diabetes prevention with drugs. In
the recently published DREAM trial, high-risk patients given rosiglitazone
were less than half as likely to develop diabetes as those on placebo,
although there were no differences in deaths or other clinical outcomes
after three years. Also, the rosiglitazone group had increased rates of
congestive heart failure and heart disease. It would be nice to figure out a
non-pharmaceutical way to reduce the risk of this common and deadly disease.
Stuart
Derbyshire and Adam Burgess looked into the science behind banning mobile
phone use in hospitals. In an
editorial they report that there is little or no evidence that
phones can interfere with medical equipment, especially if the phones are
kept three or more feet away. Although beeping and ringing (and
conversations) may be annoying, cell phones can be useful in hospitals for
both patients and doctors. One study found that hospital doctors were more
easily reached by cell phone than by pager. Should these mobile phone bans
be removed?
Finally, it
turns out that all evidence-based medicine and then there is real
evidence-based medicine. That is, all systematic reviews and meta-analyses
are not alike. In a
study matching Cochrane group drug reviews with reviews of the
same drugs supported by industry, Anders Jørgensen and associates found,
unsurprisingly, that the industry-supported studies were less critical of
the experimental drugs and endorsed them in a more unqualified manner.
Cochrane reviews more frequently considered potential biases in the studies
and were more cautious in their recommendations.
October 7
Anti-thrombotic drugs increase the risk of
gastrointestinal bleeding. Jesper Hallas and colleagues performed a
case-control
study
of the risk of GI bleeding in patients taking one or more of these drugs.
Their study population was 1443 Danish cases of serious upper GI bleeding
and their controls were almost 58,000 age- and sex-matched adults. They
found the odds of bleeding increased by about a factor of 2 when taking
low-dose aspirin and other antithrombotics except clopidogrel individually.
When they were combined, however, the risk increased substantially. The
highest risk was for patients combining aspirin and clopidogrel. In an
accompanying
editorial
Joseph Sung advocates using proton pump inhibitors in all patients on
combined aspirin and clopidogrel, adding H. pylori prophylaxis in
those at increased risk of bleeding.
Stewart Walsh et al
discuss
the causes of new arrhythmias in patients undergoing non-cardiac surgery.
Case series reveal that more than half of these arrhythmias have non-cardiac
causes, including especially infection and sepsis. Surgeons and other
doctors who take care of postoperative patients should always search
diligently for the cause of postoperative arrhythmias, looking at possible
surgery-related causes as well as those related to acid-base disturbances
and primary cardiac disease.
Everyone seems to be talking about overweight and
obesity, but what can doctors do about it? Alison Avenell and associates
review
the ABCs of obesity management by behavior change. Successful maintenance of
weight loss seems to depend on changing both caloric intake and physical
activity patterns. The authors give tips on the characteristics of
successful diet and exercise programs.
In what
will likely be a controversial
commentary, American transplant surgeon Amy Friedman proposes legalizing
the payment of patients who donate organs while still alive. She argues that
a regulated payment system would increase both donations and donor safety,
destroy the black market, and benefit donors, who are the only ones in the
current process who don’t get rewarded.
This week's US Highlights
were compiled by Birte Twisselmann, assistant editor (web).
Archive of US Highlights
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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
October
14
Bone health in children
Amy Joy Lanou
Prevention of diabetes
Carl Heneghan
et al
Use of mobile phones in hospitals
Stuart W G Derbyshire, Adam Burgess
Effects of calcium supplementation on bone density in healthy children:
meta-analysis of randomised controlled trials
Tania Winzenberg
et al
Cochrane reviews compared with industry supported meta-analyses and other
meta-analyses of the same drugs: systematic review
Anders W Jørgensen
et al
October 7
Combining aspirin with antithrombotic agents
Joseph J Y Sung
New
arrhythmias after non-cardiothoracic surgery
Stewart R Walsh et al
Use of
single and combined antithrombotic therapy and risk of serious upper
gastrointestinal bleeding: population based case-control study
Jesper Hallas et al
abc of
obesity
Management: Part I—Behaviour change, diet, and activity
Alison Avenell, Naveed Sattar, Mike Lean
Payment for living organ donation should be legalised
Amy L Friedman
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