Wednesday, May 28, 2003
Volume 326, Number 7399, Issue of 24 May 2003
Women with fatigue who are not anaemic may benefit from iron supplementation
Fatigue after one month decreased by 30% in women taking iron, and by 13% in the placebo group. Subgroup analysis showed that the effect may be restricted to women with low or borderline serum ferritin concentrations.
Women with fatigue who are not anaemic may benefit from iron supplementation
Fatigue after one month decreased by 30% in women taking iron, and by 13% in the placebo group. Subgroup analysis showed that the effect may be restricted to women with low or borderline serum ferritin concentrations.
Volume 326, Number 7399, Issue of 24 May 2003
"test for Helicobacter pylori and treat" strategy is more effective than treatment with a proton pump inhibitor for managing dyspepsia in young patients. (under 45)
empirical treatment with omeprazole compared with test and treat (urea breath test for H pylori followed by eradication treatment if necessary or by omeprazole alone). With the test and treat strategy, symptoms resolved in many patients and the need for endoscopy was reduced, whereas symptoms usually recurred after a trial of omeprazole. The authors conclude that test and treat should be the preferred option if empirical treatment of dyspepsia is to be performed.
"test for Helicobacter pylori and treat" strategy is more effective than treatment with a proton pump inhibitor for managing dyspepsia in young patients. (under 45)
empirical treatment with omeprazole compared with test and treat (urea breath test for H pylori followed by eradication treatment if necessary or by omeprazole alone). With the test and treat strategy, symptoms resolved in many patients and the need for endoscopy was reduced, whereas symptoms usually recurred after a trial of omeprazole. The authors conclude that test and treat should be the preferred option if empirical treatment of dyspepsia is to be performed.
Volume 326, Number 7399, Issue of 24 May 2003
Stepping down the dose of inhaled corticosteroids in patients with chronic stable asthma can reduce the amount taken without compromising asthma control.
Stepping down the dose of inhaled corticosteroids in patients with chronic stable asthma can reduce the amount taken without compromising asthma control.
BMJ 2003;326:997-998 ( 10 May )
No-fault compensation systems
The long overdue white paper on the reform of the clinical negligence compensation system is much awaited. Reforms to be considered include fixed tariffs for specific injuries, no-fault compensation, alternative dispute resolution, structured payouts instead of large one-off lump sums, and alternative non-cash methods of compensation such as home nursing care.
The current system is based on the law of tort, which requires the claimant to prove harm caused by a breech of the duty of care. The adversarial and blame orientated nature of this system is not conducive to the culture of openness required by clinical governance and the NHS Plan. Supporters of the current system point to the threat of litigation as a deterrent to substandard care, although the evidence does not support this. Levels of medical litigation are five times as high in the United States than Canada, but no evidence exists that doctors in the United States deliver superior care. Any deterrent role is becoming increasingly redundant in the face of more effective risk management, clinical governance, peer review, and monitoring by hospital authorities and the General Medical Council.
In no-fault liability the claimant must show that the medical error was a causative factor in the resultant injury, irrespective of who is to blame (proof of causation rather than proof of fault).
The BMA regards the present system as harmful, unpredictable, and unjust for both patients and medical staff. In the BMA model a no-fault compensation fund would handle compensation after causation is proved at a local level. The fund panel would work out compensation according to predetermined criteria. Smaller claims would be settled by individual trusts through the complaints procedure. Drug errors would be excluded as too complicated and expensive.5 A no-fault system in clinical negligence care would not be unique in the United Kingdomsimilar systems exist in workmen's compensation schemes and police injury cases.
In the United Kingdom a no-fault system would increase compliance with the mandatory reporting of adverse clinical events and would facilitate the culture of openness demanded by clinical governance, the NHS Plan, and the modern approach to look for errors in the organisations instead of blaming individuals. 11 12 It should be introduced on a limited pilot basis and monitored closely for some years.
medicolegal
No-fault compensation systems
The long overdue white paper on the reform of the clinical negligence compensation system is much awaited. Reforms to be considered include fixed tariffs for specific injuries, no-fault compensation, alternative dispute resolution, structured payouts instead of large one-off lump sums, and alternative non-cash methods of compensation such as home nursing care.
The current system is based on the law of tort, which requires the claimant to prove harm caused by a breech of the duty of care. The adversarial and blame orientated nature of this system is not conducive to the culture of openness required by clinical governance and the NHS Plan. Supporters of the current system point to the threat of litigation as a deterrent to substandard care, although the evidence does not support this. Levels of medical litigation are five times as high in the United States than Canada, but no evidence exists that doctors in the United States deliver superior care. Any deterrent role is becoming increasingly redundant in the face of more effective risk management, clinical governance, peer review, and monitoring by hospital authorities and the General Medical Council.
In no-fault liability the claimant must show that the medical error was a causative factor in the resultant injury, irrespective of who is to blame (proof of causation rather than proof of fault).
The BMA regards the present system as harmful, unpredictable, and unjust for both patients and medical staff. In the BMA model a no-fault compensation fund would handle compensation after causation is proved at a local level. The fund panel would work out compensation according to predetermined criteria. Smaller claims would be settled by individual trusts through the complaints procedure. Drug errors would be excluded as too complicated and expensive.5 A no-fault system in clinical negligence care would not be unique in the United Kingdomsimilar systems exist in workmen's compensation schemes and police injury cases.
In the United Kingdom a no-fault system would increase compliance with the mandatory reporting of adverse clinical events and would facilitate the culture of openness demanded by clinical governance, the NHS Plan, and the modern approach to look for errors in the organisations instead of blaming individuals. 11 12 It should be introduced on a limited pilot basis and monitored closely for some years.
medicolegal
Volume 326, Number 7397, Issue of 10 May 2003
Selective serotonin reuptake inhibitors and tricyclic antidepressants are equally effective when given to patients in primary care, concludes a systematic review, but more patients taking tricyclic antidepressants withdraw from treatment. - depression
Selective serotonin reuptake inhibitors and tricyclic antidepressants are equally effective when given to patients in primary care, concludes a systematic review, but more patients taking tricyclic antidepressants withdraw from treatment. - depression
Volume 326, Number 7397, Issue of 10 May 2003
In England and Wales deaths due to co-proxamol overdose represented 18% of all drug poisoning deaths and contributed 5% of all suicides.The risk of death associated with an overdose with co-proxamol seems to be far higher than for tricyclic antidepressants or paracetamol. Restricting availability of co-proxamol could help to reduce the number of suicides due to drug overdose.
In England and Wales deaths due to co-proxamol overdose represented 18% of all drug poisoning deaths and contributed 5% of all suicides.The risk of death associated with an overdose with co-proxamol seems to be far higher than for tricyclic antidepressants or paracetamol. Restricting availability of co-proxamol could help to reduce the number of suicides due to drug overdose.
Friday, May 23, 2003
Thursday, May 22, 2003
BMJ 2003; 326: 1045-1046
Finding the age of the patient's heart
Electron beam computed tomography detects early coronary atherosclerosis
Studies comparing coronary angiography with intravascular ultrasound, the reference standard for detection of atherosclerotic disease, have shown that vascular remodelling accompanies the early stages of the development of atherosclerotic plaque, and luminal narrowing therefore often does not occur until a clinically significant amount of intimal plaque has been formed.2 About 70% of acute coronary syndromes occur from rupture of haemodynamically insignificant or non-obstructive coronary artery plaquesw1 in previously asymptomatic individuals. The need is growing to identify accurately asymptomatic patients with a sizeable burden of coronary atherosclerotic plaque for intensive treatment.
Electron beam computed tomography (G E Imatron, South San Francisco, California) is an evolving, non-invasive technique for the detection of calcium in the coronary atherosclerotic plaque,4 which can also accurately quantify the extent of coronary calcification, commonly expressed as Agatston units or volumetric scores.
Callister et al evaluated the independent and additional prognostic value of coronary artery calcification scores and showed that five year survival rates worsened with increasing calcification as evidenced by coronary artery scores.6 The authors also propose a concept of "heart age," whereby coronary calcium scores derived by electron beam computed tomography are used to predict an individual's risk of death or myocardial infarction. The patients are then assigned the heart age that corresponds to their level of risk. This novel concept could improve patients' understanding and effectively replace biological age as a risk factor in the Framingham equation, which is used to assess risk of coronary heart disease.
Electron beam computed tomography uses an electronically steered electron beam to generate x rays, thus permitting rapid acquisition of gated images of a moving target such as the heart. Holding breath for 30-40 seconds produces reproducible measurements of a high quality
which represents the burden of coronary artery plaque.4 In addition electron beam computed tomography has a low radiation dose (twice that of a chest x ray or a fifth of the dose of conventional computed tomography of the chest). The absence of coronary calcium is associated with a very low rate of future cardiac events (0.1% per year)8 and has 99% negative predictive value for the presence of obstructive coronary artery disease. Callister et al have also shown that a coronary artery calcification score of less than 10 is associated with a five year survival rate of 99%.
Finding the age of the patient's heart
Electron beam computed tomography detects early coronary atherosclerosis
Studies comparing coronary angiography with intravascular ultrasound, the reference standard for detection of atherosclerotic disease, have shown that vascular remodelling accompanies the early stages of the development of atherosclerotic plaque, and luminal narrowing therefore often does not occur until a clinically significant amount of intimal plaque has been formed.2 About 70% of acute coronary syndromes occur from rupture of haemodynamically insignificant or non-obstructive coronary artery plaquesw1 in previously asymptomatic individuals. The need is growing to identify accurately asymptomatic patients with a sizeable burden of coronary atherosclerotic plaque for intensive treatment.
Electron beam computed tomography (G E Imatron, South San Francisco, California) is an evolving, non-invasive technique for the detection of calcium in the coronary atherosclerotic plaque,4 which can also accurately quantify the extent of coronary calcification, commonly expressed as Agatston units or volumetric scores.
Callister et al evaluated the independent and additional prognostic value of coronary artery calcification scores and showed that five year survival rates worsened with increasing calcification as evidenced by coronary artery scores.6 The authors also propose a concept of "heart age," whereby coronary calcium scores derived by electron beam computed tomography are used to predict an individual's risk of death or myocardial infarction. The patients are then assigned the heart age that corresponds to their level of risk. This novel concept could improve patients' understanding and effectively replace biological age as a risk factor in the Framingham equation, which is used to assess risk of coronary heart disease.
Electron beam computed tomography uses an electronically steered electron beam to generate x rays, thus permitting rapid acquisition of gated images of a moving target such as the heart. Holding breath for 30-40 seconds produces reproducible measurements of a high quality
which represents the burden of coronary artery plaque.4 In addition electron beam computed tomography has a low radiation dose (twice that of a chest x ray or a fifth of the dose of conventional computed tomography of the chest). The absence of coronary calcium is associated with a very low rate of future cardiac events (0.1% per year)8 and has 99% negative predictive value for the presence of obstructive coronary artery disease. Callister et al have also shown that a coronary artery calcification score of less than 10 is associated with a five year survival rate of 99%.
