Friday, September 12, 2003
BMJ 2003;327:604-608 (13 September)
Recent developments in obstetrics
Andrew H Shennan, professor of obstetrics1
1 Guy's, King's, and St Thomas's School of Medicine, St Thomas's Hospital, London SE1 7EH
Many biochemical substances, principally of placental and endothelial origin, increase in pre-eclampsia. However, their predictive value to detect susceptible women before clinical presentation is poor. As the disorder originates in the placenta, blood flow in the uterine artery is abnormal in most women destined to present with the syndrome. A population at risk can be targeted for intervention (fig 1) by using Doppler ultrasound to measure blood flow in the uterine artery in the second trimester. This biophysical test is currently the best predictor of pre-eclampsia. Positive predictive values are similar in both high and low risk groups, so 20% of women with an abnormal Doppler result will develop pre-eclampsia.1 2
Recent developments
Pre-eclampsia affects around 3% of pregnant women and accounts for 25% of all babies with a very low birth weight (< 1500 g). Doppler ultrasound of the uterine artery can identify women at risk
Low dose aspirin (75 mg) given prophylactically will reduce the chance of developing pre-eclampsia by 15%, with a similar reduction in fetal death. This should be considered in women at risk
The second trimester use of vaginal ultrasound to measure cervical length and the detection of vaginal fetal fibronectin are better predictors of preterm delivery than previous history
Although infection has a key role in the aetiology of early preterm delivery, evidence regarding the use of prophylactic antibiotics is contradictory since benefit may be related to the choice, route, and timing of treatment
There is no evidence that asymptomatic women with abnormal vaginal flora benefit from antimicrobials
Women with a breech presentation at term who plan a vaginal delivery have a 3% increased risk of death or serious morbidity to their baby. External cephalic version should therefore be offered
Intrapartum intervention can be reduced by avoiding unnecessary electronic fetal monitoring, encouraging vaginal delivery with previous caesarean section, and using low dose epidurals
Recent developments in obstetrics
Andrew H Shennan, professor of obstetrics1
1 Guy's, King's, and St Thomas's School of Medicine, St Thomas's Hospital, London SE1 7EH
Many biochemical substances, principally of placental and endothelial origin, increase in pre-eclampsia. However, their predictive value to detect susceptible women before clinical presentation is poor. As the disorder originates in the placenta, blood flow in the uterine artery is abnormal in most women destined to present with the syndrome. A population at risk can be targeted for intervention (fig 1) by using Doppler ultrasound to measure blood flow in the uterine artery in the second trimester. This biophysical test is currently the best predictor of pre-eclampsia. Positive predictive values are similar in both high and low risk groups, so 20% of women with an abnormal Doppler result will develop pre-eclampsia.1 2
Recent developments
Pre-eclampsia affects around 3% of pregnant women and accounts for 25% of all babies with a very low birth weight (< 1500 g). Doppler ultrasound of the uterine artery can identify women at risk
Low dose aspirin (75 mg) given prophylactically will reduce the chance of developing pre-eclampsia by 15%, with a similar reduction in fetal death. This should be considered in women at risk
The second trimester use of vaginal ultrasound to measure cervical length and the detection of vaginal fetal fibronectin are better predictors of preterm delivery than previous history
Although infection has a key role in the aetiology of early preterm delivery, evidence regarding the use of prophylactic antibiotics is contradictory since benefit may be related to the choice, route, and timing of treatment
There is no evidence that asymptomatic women with abnormal vaginal flora benefit from antimicrobials
Women with a breech presentation at term who plan a vaginal delivery have a 3% increased risk of death or serious morbidity to their baby. External cephalic version should therefore be offered
Intrapartum intervention can be reduced by avoiding unnecessary electronic fetal monitoring, encouraging vaginal delivery with previous caesarean section, and using low dose epidurals
Friday, September 05, 2003
BMJ 2003;327:522 (6 September)
Wounds heal more quickly if patients are relieved of stress
Banbury Claire Laurent
Writing about emotional events can speed up the rate at which wounds heal, according to a study carried out by Suzanne Scott and colleagues from the Unit of Psychology, King’s College, London, and presented at the annual conference of the British Psychological Society’s health division this week.
Previous research by psychologists has found that disclosure of traumatic experiences has a positive effect on the immune system. But, according to Ms Scott, a doctoral student, this study takes those findings one step further by showing a clear physical effect as a result of an emotional release.
The emotional disclosure, which was the writing, was shown to have an effect on something physical, rather than just a subtle change in the immune system. These findings have implications for the development of relatively brief and easy interventions that could have beneficial effects on wound healing," said Ms Scott.
In a separate but associated study Professor John Weinman, from King’s College, London, found that it is not just levels of stress experienced by patients before they undergo surgery that affects their recovery afterwards, as has been previously found. Ongoing stresses that they experience after surgery can also have a detrimental effect on their recovery.
Professor Weinman, who gave the keynote address at the annual conference, at Staffordshire University, said, "These research findings can help patients and will be important for developing interventions for patients undergoing different types of surgery
Wounds heal more quickly if patients are relieved of stress
Banbury Claire Laurent
Writing about emotional events can speed up the rate at which wounds heal, according to a study carried out by Suzanne Scott and colleagues from the Unit of Psychology, King’s College, London, and presented at the annual conference of the British Psychological Society’s health division this week.
Previous research by psychologists has found that disclosure of traumatic experiences has a positive effect on the immune system. But, according to Ms Scott, a doctoral student, this study takes those findings one step further by showing a clear physical effect as a result of an emotional release.
The emotional disclosure, which was the writing, was shown to have an effect on something physical, rather than just a subtle change in the immune system. These findings have implications for the development of relatively brief and easy interventions that could have beneficial effects on wound healing," said Ms Scott.
In a separate but associated study Professor John Weinman, from King’s College, London, found that it is not just levels of stress experienced by patients before they undergo surgery that affects their recovery afterwards, as has been previously found. Ongoing stresses that they experience after surgery can also have a detrimental effect on their recovery.
Professor Weinman, who gave the keynote address at the annual conference, at Staffordshire University, said, "These research findings can help patients and will be important for developing interventions for patients undergoing different types of surgery
NICE issues guidance on diabetes treatments
BMJ Andrew Iles
Volume 327, Number 7414, Issue of 6 Sep 2003
The use of thiazolidinediones (glitazones) for type 2 diabetes is to be restricted, after the release of new guidelines by the National Institute for Clinical Excellence (NICE).
NICE recommends that the treatment should be offered only to patients who cannot tolerate the combination treatment of metformin and a sulphonylurea. It no longer recommends glitazones to reduce blood glucose concentrations when treatment with metformin and a sulphonylurea has failed.
BMJ Andrew Iles
Volume 327, Number 7414, Issue of 6 Sep 2003
The use of thiazolidinediones (glitazones) for type 2 diabetes is to be restricted, after the release of new guidelines by the National Institute for Clinical Excellence (NICE).
NICE recommends that the treatment should be offered only to patients who cannot tolerate the combination treatment of metformin and a sulphonylurea. It no longer recommends glitazones to reduce blood glucose concentrations when treatment with metformin and a sulphonylurea has failed.
Volume 327, Number 7414, Issue of 6 Sep 2003
Patient involvement in healthcare decisions is hard on doctors
Doctors are encouraged to involve patients in making treatment decisions, but this poses challenges for doctors. In a clinical review article, Say and Thomson (p 542) discuss these challenges, which include the extra time and effort required to elicit patients' perspectives and the negotiations needed when the preferences of the doctor and the patient differ. Doctors often do not have the interpersonal skills to sufficiently communicate risk. A dearth of appropriate information to support patients' treatment decisions is also a problem, say the authors.
Patient involvement in healthcare decisions is hard on doctors
Doctors are encouraged to involve patients in making treatment decisions, but this poses challenges for doctors. In a clinical review article, Say and Thomson (p 542) discuss these challenges, which include the extra time and effort required to elicit patients' perspectives and the negotiations needed when the preferences of the doctor and the patient differ. Doctors often do not have the interpersonal skills to sufficiently communicate risk. A dearth of appropriate information to support patients' treatment decisions is also a problem, say the authors.
Volume 327, Number 7414, Issue of 6 Sep 2003
Heart failure is more common but has better prognosis in South Asian patients
Rates of admission to hospital for heart failure are higher among South Asian people than the indigenous white population in the United Kingdom. Blackledge and colleagues (p 526) conducted a historical cohort study of 14 797 events for admission to hospital between 1998 and 2001. Admission and incidence rates were up to four times higher in South Asian patients than in white patients. At first admission for heart failure, South Asians were on average eight years younger than white patients and were more likely to have coronary heart disease and diabetes. Despite major differences in risk factors, survival outcomes are similar, if not better, among South Asian patients, the authors say.
Heart failure is more common but has better prognosis in South Asian patients
Rates of admission to hospital for heart failure are higher among South Asian people than the indigenous white population in the United Kingdom. Blackledge and colleagues (p 526) conducted a historical cohort study of 14 797 events for admission to hospital between 1998 and 2001. Admission and incidence rates were up to four times higher in South Asian patients than in white patients. At first admission for heart failure, South Asians were on average eight years younger than white patients and were more likely to have coronary heart disease and diabetes. Despite major differences in risk factors, survival outcomes are similar, if not better, among South Asian patients, the authors say.
Volume 327, Number 7414, Issue of 6 Sep 2003
Morphine improves intractable dyspnoea
Morphine can provide added relief to patients who have intractable breathlessness even though they are receiving maximal treatment for its underlying causes. In a randomised, double blind, placebo controlled, crossover study in 38 patients with predominantly chronic obstructive pulmonary disease, Abernethy and colleagues (p 523) showed that 20 mg of sustained release morphine daily improved dyspnoea scores by 7-10%, without respiratory depression or serious side effects. The authors state that the use of opioids in the management of intractable breathlessness has been controversial.
Morphine improves intractable dyspnoea
Morphine can provide added relief to patients who have intractable breathlessness even though they are receiving maximal treatment for its underlying causes. In a randomised, double blind, placebo controlled, crossover study in 38 patients with predominantly chronic obstructive pulmonary disease, Abernethy and colleagues (p 523) showed that 20 mg of sustained release morphine daily improved dyspnoea scores by 7-10%, without respiratory depression or serious side effects. The authors state that the use of opioids in the management of intractable breathlessness has been controversial.
Thursday, September 04, 2003
BMJ 2003;327:467 (30 August)
Statins may reduce risk of depression
Long term use of statins provides psychological benefits as well as reducing the risk of coronary artery disease, a new study has found ( Journal of the American College of Cardiology 2003;42: 690-6[Medline]).
Study participants were recruited from an outpatient cardiology clinic and followed for four to seven years; 80% of the participants were men, and participants' average age at the start of the study was 67 years. Patients who had had coronary artery revascularisation or had moderate to severe congestive heart failure, advanced valvular heart disease, or serious non-cardiac illness were excluded from the study. Among those enrolled, during the study period 140 participants used statins continuously, 219 used them intermittently, and 231 did not use statins at all.
The risk reduction was independent of the statins' cholesterol lowering effect. It was associated, however, with the degree of lipophilicity of the statin. Those statins that were more lipophilic were able to penetrate the brain more easily and exert their effect better than hydrophilic statins.
The study says that, although exactly how statins exert their effect is unclear, the psychological benefits may themselves be partially due to cholesterol clearing in the microvasculature allowing better brain perfusion.
Statins may reduce risk of depression
Long term use of statins provides psychological benefits as well as reducing the risk of coronary artery disease, a new study has found ( Journal of the American College of Cardiology 2003;42: 690-6[Medline]).
Study participants were recruited from an outpatient cardiology clinic and followed for four to seven years; 80% of the participants were men, and participants' average age at the start of the study was 67 years. Patients who had had coronary artery revascularisation or had moderate to severe congestive heart failure, advanced valvular heart disease, or serious non-cardiac illness were excluded from the study. Among those enrolled, during the study period 140 participants used statins continuously, 219 used them intermittently, and 231 did not use statins at all.
The risk reduction was independent of the statins' cholesterol lowering effect. It was associated, however, with the degree of lipophilicity of the statin. Those statins that were more lipophilic were able to penetrate the brain more easily and exert their effect better than hydrophilic statins.
The study says that, although exactly how statins exert their effect is unclear, the psychological benefits may themselves be partially due to cholesterol clearing in the microvasculature allowing better brain perfusion.
BMJ 2003;327:488-493 (30 August)
Prison environment worsens mental health
Long periods of being locked up with little mental stimulation is bad for the mental health of prisoners
yes as if we did not know!
Prison environment worsens mental health
Long periods of being locked up with little mental stimulation is bad for the mental health of prisoners
yes as if we did not know!
BMJ 2003;327:488-493 (30 August)
Diagnosis of autism
good article
Box 2: Alerting signals of possible autistic spectrum disorder13
In the first year of life there are usually no clear discriminating features, but parental concerns should be elicited
Between 2 and 3 years of age, concerns in the following areas should prompt referralw1
Communication
Impairment in language development, especially comprehension; unusual use of language; poor response to name; deficient non-verbal communication—for example, lack of pointing and difficulty following a point and failure to smile socially to share enjoyment and respond to the smiling of others
Absolute indicators for referral
No babble, pointing, or other gesture by 12 months
No single words by 18 months
No two word spontaneous (non-echoed) phrases by 24 months
Any loss of any language or social skills at any agew2
Social impairments
Limitation in, or lack of imitation of, actions (for example, clapping); lack of showing with toys or other objects; lack of interest in other children or odd approaches to other children. Minimal recognition or responsiveness to other people's happiness or distress; limited variety of imaginative play or pretence, especially social imagination (that is, not joining with others in shared imaginary games), "in his or her own world;" failure to initiate simple play with others or participate in early social games; preference for solitary play activities; odd relationships with adults (too friendly or ignores)
Impairment of interests, activities, and other behaviours
Over-sensitivity to sound or touch; motor mannerisms; biting, hitting, or aggression to peers; oppositional to adults; over-liking for sameness or inability to cope with change, especially in unstructured setting; repetitive play with toys (for example, lining up objects); turning light switches on and off, regardless of scolding
Box 3: Features that may discriminate children with autism in later childhood13
In school age children, the following features should alert teachers and others to the possibility of autistic spectrum disorder and trigger discussion with parents and possible implementation of the local referral pathway
Communication impairments
Abnormalities in language development, including muteness and odd or inappropriate prosody
Persistent echolalia
Reference to self as "you," "she," or "he" beyond 3 years
Unusual vocabulary for child's age or social group
Limited use of language for communication or tendency to talk freely only about specific topics
Social impairments
Inability to join in with the play of other children or inappropriate attempts at joint play (may manifest as aggressive or disruptive behaviour)
Lack of awareness of classroom "norms" (criticising teachers; overt unwillingness to cooperate in classroom activities; inability to appreciate or follow current trends—for example, with regard to other children's dress, style of speech, or interests)
Easily overwhelmed by social and other stimulation
Failure to relate normally to adults (too intense or no relationship)
Showing extreme reactions to invasion of personal space and extreme resistance to being "hurried"
Box 6: Associated developmental and mental health impairments (comorbidities)
Studies have suggested that 75% of children diagnosed as having autism will have some learning difficulty. The current figure of 20-25% without learning difficulty may well be an underestimate; the figure is likely to increase as higher functioning children are increasingly given a diagnosis of autism
Specific learning difficulties of attention, processing speed, working memory, and other tasks often thought of as executive skills are often impaired in autistic spectrum disorder and contribute to the common observation of a gap between structured test results where no or few problems are shown and daily functioning in real life where marked impairment is found
Writing difficulties can create a major barrier to output for many high functioning children. Increasingly, the use of a laptop computer gets around a problem that often threatens to affect the attitude of the child to the entire educational process
The lifetime risk of epilepsy is increased. Early studies suggested that up to a third of children with autism will develop epilepsy either in early childhood or in adolescence (many had learning difficulties, and more recent estimates suggest that prevalence is lower—about 17%)
Learning disabilities in general are a risk factor for behavioural problems; 41% of children with mild to moderate or severe learning difficulties have severe emotional behavioural disturbance. Children with autism have double the rate of "caseness" of psychiatric disorder compared with those with learning difficultiesw5
In high functioning autism the risk of psychiatric disorders is also increased. In a Canadian study 17% of such children were more than two standard deviations above the population mean for attention deficit hyperactivity disorder and depression, as were 13.5% for anxiety. Other problems of motor coordination, sleeping, eating, and elimination are also more common in autismw4
The association with abnormalities of bowel function awaits further research
Diagnosis of autism
good article
Box 2: Alerting signals of possible autistic spectrum disorder13
In the first year of life there are usually no clear discriminating features, but parental concerns should be elicited
Between 2 and 3 years of age, concerns in the following areas should prompt referralw1
Communication
Impairment in language development, especially comprehension; unusual use of language; poor response to name; deficient non-verbal communication—for example, lack of pointing and difficulty following a point and failure to smile socially to share enjoyment and respond to the smiling of others
Absolute indicators for referral
No babble, pointing, or other gesture by 12 months
No single words by 18 months
No two word spontaneous (non-echoed) phrases by 24 months
Any loss of any language or social skills at any agew2
Social impairments
Limitation in, or lack of imitation of, actions (for example, clapping); lack of showing with toys or other objects; lack of interest in other children or odd approaches to other children. Minimal recognition or responsiveness to other people's happiness or distress; limited variety of imaginative play or pretence, especially social imagination (that is, not joining with others in shared imaginary games), "in his or her own world;" failure to initiate simple play with others or participate in early social games; preference for solitary play activities; odd relationships with adults (too friendly or ignores)
Impairment of interests, activities, and other behaviours
Over-sensitivity to sound or touch; motor mannerisms; biting, hitting, or aggression to peers; oppositional to adults; over-liking for sameness or inability to cope with change, especially in unstructured setting; repetitive play with toys (for example, lining up objects); turning light switches on and off, regardless of scolding
Box 3: Features that may discriminate children with autism in later childhood13
In school age children, the following features should alert teachers and others to the possibility of autistic spectrum disorder and trigger discussion with parents and possible implementation of the local referral pathway
Communication impairments
Abnormalities in language development, including muteness and odd or inappropriate prosody
Persistent echolalia
Reference to self as "you," "she," or "he" beyond 3 years
Unusual vocabulary for child's age or social group
Limited use of language for communication or tendency to talk freely only about specific topics
Social impairments
Inability to join in with the play of other children or inappropriate attempts at joint play (may manifest as aggressive or disruptive behaviour)
Lack of awareness of classroom "norms" (criticising teachers; overt unwillingness to cooperate in classroom activities; inability to appreciate or follow current trends—for example, with regard to other children's dress, style of speech, or interests)
Easily overwhelmed by social and other stimulation
Failure to relate normally to adults (too intense or no relationship)
Showing extreme reactions to invasion of personal space and extreme resistance to being "hurried"
Box 6: Associated developmental and mental health impairments (comorbidities)
Studies have suggested that 75% of children diagnosed as having autism will have some learning difficulty. The current figure of 20-25% without learning difficulty may well be an underestimate; the figure is likely to increase as higher functioning children are increasingly given a diagnosis of autism
Specific learning difficulties of attention, processing speed, working memory, and other tasks often thought of as executive skills are often impaired in autistic spectrum disorder and contribute to the common observation of a gap between structured test results where no or few problems are shown and daily functioning in real life where marked impairment is found
Writing difficulties can create a major barrier to output for many high functioning children. Increasingly, the use of a laptop computer gets around a problem that often threatens to affect the attitude of the child to the entire educational process
The lifetime risk of epilepsy is increased. Early studies suggested that up to a third of children with autism will develop epilepsy either in early childhood or in adolescence (many had learning difficulties, and more recent estimates suggest that prevalence is lower—about 17%)
Learning disabilities in general are a risk factor for behavioural problems; 41% of children with mild to moderate or severe learning difficulties have severe emotional behavioural disturbance. Children with autism have double the rate of "caseness" of psychiatric disorder compared with those with learning difficultiesw5
In high functioning autism the risk of psychiatric disorders is also increased. In a Canadian study 17% of such children were more than two standard deviations above the population mean for attention deficit hyperactivity disorder and depression, as were 13.5% for anxiety. Other problems of motor coordination, sleeping, eating, and elimination are also more common in autismw4
The association with abnormalities of bowel function awaits further research
Volume 327, Number 7413, Issue of 30 Aug 2003
Ordinary activity is as good as exercises or relaxation for neck pain
Dynamic muscle training and relaxation training are no better for neck pain or neck related disability than ordinary physical activity. Viljanen and colleagues (p 475) randomised 393 women office workers with chronic neck pain to dynamic muscle training, relaxation training, or ordinary activity (controls). The range of motion for rotation and lateral flexion in the neck region improved slightly more in the training groups than in the control group, but no other differences in neck pain were found between the three groups at three, six, or 12 months. Neck pain is common, affecting an estimated two thirds of people during their adult lives.
Ordinary activity is as good as exercises or relaxation for neck pain
Dynamic muscle training and relaxation training are no better for neck pain or neck related disability than ordinary physical activity. Viljanen and colleagues (p 475) randomised 393 women office workers with chronic neck pain to dynamic muscle training, relaxation training, or ordinary activity (controls). The range of motion for rotation and lateral flexion in the neck region improved slightly more in the training groups than in the control group, but no other differences in neck pain were found between the three groups at three, six, or 12 months. Neck pain is common, affecting an estimated two thirds of people during their adult lives.
Volume 327, Number 7413, Issue of 30 Aug 2003
Bisphosphonates reduce skeletal morbidity in cancer patients
In patients with metastatic bone disease bisphosphonates reduce skeletal morbidity and increase the time to first skeletal related event. In a systematic review of 30 randomised controlled trials, Ross and colleagues (p 469) found that bisphosphonates significantly decrease the risk of vertebral fractures, non-vertebral fractures, radiotherapy, and hypercalcaemia but not orthopaedic surgery or spinal cord compression. They also delay the time to first skeletal related event, suggesting that bisphosphonates should be started when bone metastases are diagnosed.
Bisphosphonates reduce skeletal morbidity in cancer patients
In patients with metastatic bone disease bisphosphonates reduce skeletal morbidity and increase the time to first skeletal related event. In a systematic review of 30 randomised controlled trials, Ross and colleagues (p 469) found that bisphosphonates significantly decrease the risk of vertebral fractures, non-vertebral fractures, radiotherapy, and hypercalcaemia but not orthopaedic surgery or spinal cord compression. They also delay the time to first skeletal related event, suggesting that bisphosphonates should be started when bone metastases are diagnosed.
