Practical papers on clinical practiceBMJ 1998; 316 doi: https://doi.org/10.1136/bmj.316.7136.0 (Published 28 March 1998) Cite this as: BMJ 1998;316:0
The first aim of the BMJ is to help doctors practise better medicine. And as most of our readers are clinicians that means publishing information on how to manage patients better. Sometimes that can be tough to achieve because the link between research and practice may be tenuous. Two authors describe, for instance, how they approached 75 epidemiological studies on cardiovascular disease and combined oral contraceptives with a straightforward clinical question (p 984). Only five of the studies helped them directly, although 14 could have been useful if the information had been presented in a different way.
This week's BMJ does, however, do well on offering practical guidance to clinicians. More pages are devoted to material that should be directly clinically relevant than to informed consent—although that is the subject that dominates the issue (p 949). Our cluster of material on informed consent has been planned for a long time, but it comes the week after a British paediatric cardiologist was found guilty of serious professional misconduct for doing a balloon angioplasty on child when he had not been given consent to do so (p 955). Two doctors gave evidence on his behalf saying that they would have done the same, but what was acceptable a few years ago—in practice, research, and publication—is no longer acceptable.
Two of the practical clinical studies, both systematic reviews, look in different ways at the problem of transfusion. One review addresses the age old controversy of whether critically ill patients with hypovolaemia should be given colloid or crystalloid (p 961). Several guidelines advocate colloids, and an American survey showed that they were used even more than was recommended. Today's study suggests that colloid is actually associated with higher mortality—probably four extra deaths for every 100 patients treated. The authors conclude that colloids should not be used “outside randomised controlled trials in subsets of patients of particular concern.”
The second study examines whether heparin is useful in maintaining peripheral intravascular catheters (p 969). It has been used widely for over 20 years, but its use has not been established by good evidence. The authors find that using heparin at a dose of 10 U/ml to flush out catheters locked between use is no better than using normal saline. Adding heparin as a continuous infusion at a dose of 1 U/ml did, however, reduce the risk of phlebitis and extend the life of the catheter.
These two studies may well excite some readers to write to us. One observation that an old dog editor can make is that intellectually impeccable demolitions of the whole of medicine will often elicit no response while pieces on drips inflame people. Perhaps this is inevitable. You are likely to form strong opinions on something that occupies you every day and, much worse, pulls you from your bed.