Friday, March 12, 2004
BJGP march 2004 vol 54 numberr500
Normalisation :horrible word, useful idea,
Drs cannot always explain thie patient symptoms. Any symptom may be trivial or herald a seroius disease. "normalisation" concept ie you may have symptoms but you are not ill. The dr either over investigates and reinforces pt ideas that something is wrong, or explanation does not fit with pts ideas concerns and expectations.
"reattribution" technique to help pts who make persistent somatising attributions in primary care, become more psychologically minded so pt feels understood and eventually making the link with phsical and psychological issues. Technique takes time to teach to GPs
Normalisation :horrible word, useful idea,
Drs cannot always explain thie patient symptoms. Any symptom may be trivial or herald a seroius disease. "normalisation" concept ie you may have symptoms but you are not ill. The dr either over investigates and reinforces pt ideas that something is wrong, or explanation does not fit with pts ideas concerns and expectations.
"reattribution" technique to help pts who make persistent somatising attributions in primary care, become more psychologically minded so pt feels understood and eventually making the link with phsical and psychological issues. Technique takes time to teach to GPs
Wednesday, March 03, 2004
BMJ 2004;328:474-475 (28 February),
Why do doctors use treatments that do not work? For many reasons—including their inability to stand idle and do nothing
As Voltaire said, "The art of medicine consists in amusing the patient while nature cures the disease."
Why do doctors use treatments that do not work? For many reasons—including their inability to stand idle and do nothing
As Voltaire said, "The art of medicine consists in amusing the patient while nature cures the disease."
BMJ 2004;328 (28 February), doi:10.1136/bmj.328.7438.0-c
Low dose ramipril is not optimal in diabetes
Low dose (1.25 mg daily) ramipril does not reduce cardiovascular and renal events in patients with type 2 diabetes and albuminuria. After four years of follow up of 4912 diabetic patients enrolled in the DIABHYCAR trial, where participants were given low dose ramipril or standard care, Marre and colleagues (p 495) found that low dose ramipril had no effect on cardiovascular and renal outcome, but it slightly reduced albuminuria and blood pressure in the intervention group. The protective effect of ramipril may be dose dependent, the authors say, and high doses can be recommended for cardiovascular protection in high risk patients.
Low dose ramipril is not optimal in diabetes
Low dose (1.25 mg daily) ramipril does not reduce cardiovascular and renal events in patients with type 2 diabetes and albuminuria. After four years of follow up of 4912 diabetic patients enrolled in the DIABHYCAR trial, where participants were given low dose ramipril or standard care, Marre and colleagues (p 495) found that low dose ramipril had no effect on cardiovascular and renal outcome, but it slightly reduced albuminuria and blood pressure in the intervention group. The protective effect of ramipril may be dose dependent, the authors say, and high doses can be recommended for cardiovascular protection in high risk patients.
BMJ 2004;328 (28 February),
Drinking plenty of fluids may be harmful
Drinking extra fluids in the presence of acute respiratory infection may cause fluid overload and hyponatraemia, and may be harmful to patients. In a systematic review, Guppy and colleagues (p 499) report that no randomised trial compared increased or restricted fluid intake in patients with respiratory infection. Results of prevalence studies, and case series, suggest that increased fluid intake may cause harm. We should be cautious when adopting such a strategy until more evidence is available, the authors say.
Drinking plenty of fluids may be harmful
Drinking extra fluids in the presence of acute respiratory infection may cause fluid overload and hyponatraemia, and may be harmful to patients. In a systematic review, Guppy and colleagues (p 499) report that no randomised trial compared increased or restricted fluid intake in patients with respiratory infection. Results of prevalence studies, and case series, suggest that increased fluid intake may cause harm. We should be cautious when adopting such a strategy until more evidence is available, the authors say.
BMJ 2004;328:416-417 (21 February
Patients' expectations of consultations
Patient pressure may be stronger in the doctor's mind than in the patient's
v good article
Patients' expectations of consultations
Patient pressure may be stronger in the doctor's mind than in the patient's
v good article
BMJ 2004;328 (21 February),
Aspirin induced asthma is more common than previously suggested
The prevalence of aspirin induced asthma is higher than previously suggested. In a systematic review, Jenkins and colleagues (p 434) found that the prevalence of aspirin induced asthma was higher when determined by oral provocation testing than verbal history (21% v 3% in adults, 5% v 2% in children). Most patients were sensitive to NSAIDs, but sensitivity to paracetamol (7% of patients) was more likely in patients highly sensitive to aspirin. Since aspirin and other anti-inflammatory drugs are often self prescribed, patients with asthma should be alerted to the possibility of cross reaction. Simple, standardised warnings on packs of aspirin and NSAIDs may be indicated.
Aspirin induced asthma is more common than previously suggested
The prevalence of aspirin induced asthma is higher than previously suggested. In a systematic review, Jenkins and colleagues (p 434) found that the prevalence of aspirin induced asthma was higher when determined by oral provocation testing than verbal history (21% v 3% in adults, 5% v 2% in children). Most patients were sensitive to NSAIDs, but sensitivity to paracetamol (7% of patients) was more likely in patients highly sensitive to aspirin. Since aspirin and other anti-inflammatory drugs are often self prescribed, patients with asthma should be alerted to the possibility of cross reaction. Simple, standardised warnings on packs of aspirin and NSAIDs may be indicated.
BMJ 2004;328:369 (14 February),
Acute stroke units and early CT scans are linked to lower in-hospital mortality rates
Stroke is the third largest cause of death in the United Kingdom and other developed countries. Early diagnosis, including a brain scan, and treatment in a specialist hospital based stroke unit have been shown to be effective in improving outcomes. The NHS in England has recently introduced the target that all hospitals should ensure stroke patients are given a CT scan within 48 hours of admission and are treated in a specialist stroke unit. The minority of hospitals that do this are achieving significantly better in-hospital death rates.
The bottom line
Hospitals with an acute stroke unit were associated with an 11% lower odds of death in hospital
Hospitals that had rehabilitation stroke units or combined acute and rehabilitation units showed no significant difference in the odds of death
Hospitals that performed CT scans within 48 hours on all suspected stroke patients were associated with an 8% lower odds of death in hospital
Acute stroke units and early CT scans are linked to lower in-hospital mortality rates
Stroke is the third largest cause of death in the United Kingdom and other developed countries. Early diagnosis, including a brain scan, and treatment in a specialist hospital based stroke unit have been shown to be effective in improving outcomes. The NHS in England has recently introduced the target that all hospitals should ensure stroke patients are given a CT scan within 48 hours of admission and are treated in a specialist stroke unit. The minority of hospitals that do this are achieving significantly better in-hospital death rates.
The bottom line
Hospitals with an acute stroke unit were associated with an 11% lower odds of death in hospital
Hospitals that had rehabilitation stroke units or combined acute and rehabilitation units showed no significant difference in the odds of death
Hospitals that performed CT scans within 48 hours on all suspected stroke patients were associated with an 8% lower odds of death in hospital
BMJ 2004;328:371 (14 February
Benefits and harms associated with hormone replacement therapy: clinical decision analysis
Objective To evaluate harms and benefits associated with use of combined hormone replacement therapy (HRT) for five years in women with different baseline risks for breast cancer.
Conclusions HRT for primary prevention of chronic diseases in women without menopausal symptoms is unjustified. Perceived quality of life in women with symptoms should be taken into account when deciding on HRT. Thus, a decision analysis tailored to an individual woman is more appropriate in clinical practice than a population based approach.
Benefits and harms associated with hormone replacement therapy: clinical decision analysis
Objective To evaluate harms and benefits associated with use of combined hormone replacement therapy (HRT) for five years in women with different baseline risks for breast cancer.
Conclusions HRT for primary prevention of chronic diseases in women without menopausal symptoms is unjustified. Perceived quality of life in women with symptoms should be taken into account when deciding on HRT. Thus, a decision analysis tailored to an individual woman is more appropriate in clinical practice than a population based approach.
BMJ 2004;328:297-298 (7 February
Secondary prevention for stroke and transient ischaemic attacks
In PROGRESS, 6105 patients who had had a stroke or transient ischaemic attack an average of six months previously were randomised to get 4 mg of perindopril, a long acting angiotensin converting enzyme (ACE) inhibitor prodrug, in combination with indapamide 2 mg or 2.5 mg (at the discretion of the treating clinician—not randomised), or to matching placebo(s), in addition to other antihypertensive drugs. Over four years the relative risk of stroke was reduced as predicted by 28%, with a similar reduction in all cause cardiovascular morbidity. In PROGRESS, patients with intracerebral haemorrhage benefited perhaps even more than those with ischaemic events. Overall the absolute benefit was 3.7% over four years (NNT = 27).
In the lowest tertile of blood pressure at entry to PROGRESS mean blood pressure was 128/77 mm Hg. These patients had an identical reduction in relative risk compared with higher tertiles and an absolute reduction for stroke of 4.3% (NNT = 23) while taking combination treatment.
In the face of these results definitions of hypertension and hypercholesterolaemia in any patient with stroke or transient ischaemic attack seem artificial. Irrespective of starting levels of blood pressure almost all patients may benefit from treatment to reduce blood pressure and cholesterol.
Secondary prevention for stroke and transient ischaemic attacks
In PROGRESS, 6105 patients who had had a stroke or transient ischaemic attack an average of six months previously were randomised to get 4 mg of perindopril, a long acting angiotensin converting enzyme (ACE) inhibitor prodrug, in combination with indapamide 2 mg or 2.5 mg (at the discretion of the treating clinician—not randomised), or to matching placebo(s), in addition to other antihypertensive drugs. Over four years the relative risk of stroke was reduced as predicted by 28%, with a similar reduction in all cause cardiovascular morbidity. In PROGRESS, patients with intracerebral haemorrhage benefited perhaps even more than those with ischaemic events. Overall the absolute benefit was 3.7% over four years (NNT = 27).
In the lowest tertile of blood pressure at entry to PROGRESS mean blood pressure was 128/77 mm Hg. These patients had an identical reduction in relative risk compared with higher tertiles and an absolute reduction for stroke of 4.3% (NNT = 23) while taking combination treatment.
In the face of these results definitions of hypertension and hypercholesterolaemia in any patient with stroke or transient ischaemic attack seem artificial. Irrespective of starting levels of blood pressure almost all patients may benefit from treatment to reduce blood pressure and cholesterol.
