Some help with your clinical dilemmasBMJ 2019; 364 doi: https://doi.org/10.1136/bmj.l693 (Published 14 February 2019) Cite this as: BMJ 2019;364:l693
- Fiona Godlee, editor in chief
Follow Fiona on Twitter @fgodlee
Healthcare is not short of dilemmas. What’s best for this patient? What interventions should we fund and not fund? Which research should we put into practice? This week we tackle a few.
Firstly: is subacromial decompression surgery the best approach for patients with shoulder pain? In the latest in our Rapid Recommendations series (doi:10.1136/bmj.l294), Per Olav Vandvik and colleagues conclude that it isn’t. On the basis of two recent randomised controlled trials and two systematic reviews, the panel of medical experts and patients found that, though surgery gave slightly better outcomes than physical therapy, it also carried greater risk of serious harms.
Their strong recommendation against surgery is reminiscent of one of our first Rapid Recommendations in 2017, which strongly recommended against arthroscopic surgery for knee arthritis and meniscal tear (doi:10.1136/bmj.j1982). But this time we have an accompanying plea not to dismiss arthroscopic shoulder surgery out of hand. In their editorial Nick Aresti and Livio Di Mascio acknowledge that surgery is overused but worry about the quality of the evidence behind this new guidance (doi:10.1136/bmj.l586). “Healthcare professionals should be more cautious in their approach to arthroscopic subacromial decompression,” they say, “but the current evidence base is not strong enough to condemn it.”
Next is the question of screening for atrial fibrillation. The arguments for population screening seem sound. Atrial fibrillation is on the rise, many strokes are caused by it, and it increases the risk of heart failure, myocardial infarction, and dementia, says Mark Lown (doi:10.1136/bmj.l43). Screening with a single lead ECG is cheap, non-invasive, and convenient, and treatment with anticoagulants is reasonably well tolerated and effective. But Patrick Moran argues that we don’t yet know the real risk of stroke in untreated atrial fibrillation, nor whether increased detection leads to better clinical outcomes (doi:10.1136/bmj.l43). Before embarking on a path of no (or at least difficult) return, we should wait for the results of ongoing randomised controlled trials, he says.
Finally, should patients who have a cardiac arrest outside hospital be intubated, or is a supraglottic airway device just as good? Randomised trials in this condition are rare and hard to do. One cleverly designed trial is summarised this week, in the first of a new series from the National Institute for Health Research (NIHR). It finds no significant difference in survival, neurological disability, or complication rate between tracheal intubation and the easier and less invasive insertion of an airway (doi:10.1136/bmj.k5324).
Knowing which research to put into practice is hard. Our new NIHR Signals series will provide fortnightly summaries of high quality and clinically relevant research, written in plain English with declarative titles and clearly stated key messages. As explained by The BMJ’s Sophie Cook and coauthors from the NIHR’s dissemination unit, it’s a noisy world out there (doi:10.1136/bmj.l513). We hope this new series will help you identify the research signals most likely to help your patients, inform your practice, and improve the quality of care.