Friday, May 28, 2004
BMJ 2004;328:1312-1315 (29 May), doi:10.1136/bmj.328.7451.1312
Hands-on guide to questionnaire research
Selecting, designing, and developing your questionnaire
Good article for research
Hands-on guide to questionnaire research
Selecting, designing, and developing your questionnaire
Good article for research
BMJ 2004;328:1273-1274 (29 May), doi:10.1136/bmj.328.7451.1273
NICE guidance on newer drugs for epilepsy in adults
Individualisation of therapy remains the key to successful treatment
The conclusions reached are: firstly, monotherapy data in newly diagnosed patients do not show the existence of differences in effectiveness between newer and older antiepileptic drugs; secondly, although side effect profiles and interaction potential differ among drugs, adequate evidence does not exist to support the claim that newer drugs are generally associated with improved quality of life; thirdly, integrated cost effectiveness analysis shows a high degree of uncertainty about the costs and benefits associated with individual drugs; fourthly, seizure freedom, the most important outcome, is infrequently achieved during combination therapy in patients refractory to monotherapy, and insufficient evidence exists to determine whether any one of the newer antiepileptic drugs is superior to others in providing long term freedom from seizures. Overall, these conclusions agree with those reached in previous publications, including Cochrane reviews.1 3 Some of the studies showing improved outcome with newer antiepileptic drugs may in fact have been flawed by bias in study design or analysis.4
The guidance recommends that people with a first seizure be referred to a specialist for accurate diagnosis. If treatment is indicated (which is normally the case after two seizures have occurred), this should be initiated with a single drug, and combination therapy should be attempted only when at least two sequentially tried individual drugs have failed. Treatment should be monitored regularly and revert ultimately to the regimen (monotherapy or polytherapy) that proved most acceptable in terms of seizure control and side effects. As for the place of newer antiepileptic drugs, the guidance recommends that these be reserved for people who have not benefited from older agents such as carbamazepine or valproate. However, new antiepileptic drugs may be used as first line treatments when older antiepileptic drugs are contraindicated or are already known to be poorly tolerated by the individual, or when they are expected to interact with other drugs the patient is taking (most notably oral contraceptives) or when the patient is a woman of childbearing potential. In the latter situation, the guidance highlights the need for counselling on contraception (phenytoin, carbamazepine, barbiturates, oxcarbazepine, and felbamate reduce the efficacy of the contraceptive pill, whereas valproate, lamotrigine, gabapentin, lamotrigine, levetiracetam, tiagabine, vigabatrin, zonisamide and, at doses up to 200 mg/day, topiramate, do not5) and risks for the unborn child, specific caution being given against valproate because of risks for the unborn child.
comment: need good access to neurology to get the ball rolling, prob quite a specialist area
NICE guidance on newer drugs for epilepsy in adults
Individualisation of therapy remains the key to successful treatment
The conclusions reached are: firstly, monotherapy data in newly diagnosed patients do not show the existence of differences in effectiveness between newer and older antiepileptic drugs; secondly, although side effect profiles and interaction potential differ among drugs, adequate evidence does not exist to support the claim that newer drugs are generally associated with improved quality of life; thirdly, integrated cost effectiveness analysis shows a high degree of uncertainty about the costs and benefits associated with individual drugs; fourthly, seizure freedom, the most important outcome, is infrequently achieved during combination therapy in patients refractory to monotherapy, and insufficient evidence exists to determine whether any one of the newer antiepileptic drugs is superior to others in providing long term freedom from seizures. Overall, these conclusions agree with those reached in previous publications, including Cochrane reviews.1 3 Some of the studies showing improved outcome with newer antiepileptic drugs may in fact have been flawed by bias in study design or analysis.4
The guidance recommends that people with a first seizure be referred to a specialist for accurate diagnosis. If treatment is indicated (which is normally the case after two seizures have occurred), this should be initiated with a single drug, and combination therapy should be attempted only when at least two sequentially tried individual drugs have failed. Treatment should be monitored regularly and revert ultimately to the regimen (monotherapy or polytherapy) that proved most acceptable in terms of seizure control and side effects. As for the place of newer antiepileptic drugs, the guidance recommends that these be reserved for people who have not benefited from older agents such as carbamazepine or valproate. However, new antiepileptic drugs may be used as first line treatments when older antiepileptic drugs are contraindicated or are already known to be poorly tolerated by the individual, or when they are expected to interact with other drugs the patient is taking (most notably oral contraceptives) or when the patient is a woman of childbearing potential. In the latter situation, the guidance highlights the need for counselling on contraception (phenytoin, carbamazepine, barbiturates, oxcarbazepine, and felbamate reduce the efficacy of the contraceptive pill, whereas valproate, lamotrigine, gabapentin, lamotrigine, levetiracetam, tiagabine, vigabatrin, zonisamide and, at doses up to 200 mg/day, topiramate, do not5) and risks for the unborn child, specific caution being given against valproate because of risks for the unborn child.
comment: need good access to neurology to get the ball rolling, prob quite a specialist area
BMJ 2004;328 (29 May), doi:10.1136/bmj.328.7451.0-d
HRT increases unnecessary tests after breast cancer screening
Useless tests after initial screening for breast cancer are more likely in women who are, or were, taking hormone replacement therapy. Banks and colleagues (p 1291) reviewed data from more than 87 000 postmenopausal women screened in the NHS, and found that 3% of those with a negative screening had subsequent tests. Tests (and biopsies) were more likely in women still taking hormone replacement therapy and in past users.
comment: another reason fro not prescribing HRT
HRT increases unnecessary tests after breast cancer screening
Useless tests after initial screening for breast cancer are more likely in women who are, or were, taking hormone replacement therapy. Banks and colleagues (p 1291) reviewed data from more than 87 000 postmenopausal women screened in the NHS, and found that 3% of those with a negative screening had subsequent tests. Tests (and biopsies) were more likely in women still taking hormone replacement therapy and in past users.
comment: another reason fro not prescribing HRT
BMJ 2004;328 (29 May), doi:10.1136/bmj.328.7451.0-a
Soya food may reduce the risk of endometrial cancer Regular consumption of soya may decrease the risk of endometrial cancer. Xu and colleagues (p 1285) studied 1678 women in China (832 with endometrial cancer) and found that, compared with the quarter of women with the lowest soya protein intake, the risk of endometrial cancer was reduced with increasing soya protein intake. The reduction was more pronounced among women with high body mass index or waist:hip ratio.
comment: as soya is also a good "food" for nmenopause it may kill 2 birds with one stone, and good to hear that it helps those with high BMI, alos in study were women from 30-69 so good age spread.
Soya food may reduce the risk of endometrial cancer Regular consumption of soya may decrease the risk of endometrial cancer. Xu and colleagues (p 1285) studied 1678 women in China (832 with endometrial cancer) and found that, compared with the quarter of women with the lowest soya protein intake, the risk of endometrial cancer was reduced with increasing soya protein intake. The reduction was more pronounced among women with high body mass index or waist:hip ratio.
comment: as soya is also a good "food" for nmenopause it may kill 2 birds with one stone, and good to hear that it helps those with high BMI, alos in study were women from 30-69 so good age spread.
Sunday, May 23, 2004
BMJ 2004;328:1215-1216 (22 May), doi:10.1136/bmj.328.7450.1215
Inhaled insulin
Two versions, a powder and an aerosol, may be nearing launch
The bioavailability is 10-15% and the dose equivalent about three times that of injected insulin. The pharmacodynamics of inhaled insulin offer an action profile with a fast onset (although slightly longer run-off) akin to that of rapid acting insulin analogues given subcutaneously, which in studies have shown better postprandial glucose control and less tendency to nocturnal hypoglycaemia.2 3 A Cochrane review of randomised controlled trials comparing inhaled with injected short acting unmodified human insulin used for prandial insulin replacement, in conjunction with a basal injected insulin, concluded that inhaled insulin provided equivalent control to fully injected regimens.
But there were drawbacks in the insulin injection regimes (see paper)
In patients with type 2 diabetes, adding inhaled insulin to oral hypoglycaemic regimens does improve control more than doing nothing.5
The advantages of inhaled over injected insulins to date relate to patients' preferences. This is important—apart from patients' comfort, an expensive new insulin could have huge potential advantage if it encouraged adherence and resulted in more patients with diabetes achieving treatment targets. Sadly, the published data on patients' satisfaction, superficially encouraging, are difficult to interpret, as invariably patients have been comparing a new treatment with an old one. When a specially designed questionnaire was used, treatment satisfaction improved significantly in patients with type 1 and type 2 diabetes on taking part in the trials, irrespective of whether the mealtime insulins they took were injected or inhaled.6-8
Notably, improvement in treatment satisfaction correlated with improved glycaemic control. Might greater satisfaction have been obtained with injected regimens if these had been optimised effectively? Were the studies just too short to show the biomedical gains one might anticipate from a treatment expressly designed to support compliance, or do the problems of insulin therapy extend beyond a dislike of needles?
Inhaled insulin has potential problems. The bioavailability is affected by asthma (decreased) and smoking (increased).9 10 Of course, if patients really dislike injections so much inhaled insulin might make its biggest impact on complications of diabetes if it were to be available only to proved non-smokers. Formation of anti-insulin antibodies is higher with inhaled insulin, and although this is dismissed as not affecting insulin requirement over time, older diabetologists will remember the drive to reduce insulin antibody formation, with the fears that antibodies delay and render unpredictable insulin absorption and even that antibody-antigen complexes may increase risk of microvascular disease.11 Finally, there have been concerns about possible long term effects of insulin on lung structure and function, although current published trials report no deleterious effects over the short-term.
For patients with established type 1 diabetes lack of freedom to eat or not eat and the demand for (painful) blood glucose testing may be much more of an issue than injection therapy itself.12 In one study only 14% of injections were missed because they were injections.13 In this group healthcare providers will need more robust evidence of patients' preference than is currently available. Where inhaled insulins could really have an impact (in the developed world) will be if healthcare professionals and patients start to use insulin much earlier and more aggressively in type 2 diabetes, affecting the progression of diabetic complications. In the developing world, where cultural taboos against injection treatments may be even more real than here, inhaled insulin may be expected to deliver more in terms of health benefit—but is not likely to be more affordable or available than the currently inadequate supplies of injected insulin. Meanwhile, all patients are waiting to see if the new inhalations are safe. If they are, and if they are cheap enough, at least one barrier to better diabetes treatment may fall.
comment: at last a new way of administering insulin which may be more pateint friendly. But there are potential problems.
Inhaled insulin
Two versions, a powder and an aerosol, may be nearing launch
The bioavailability is 10-15% and the dose equivalent about three times that of injected insulin. The pharmacodynamics of inhaled insulin offer an action profile with a fast onset (although slightly longer run-off) akin to that of rapid acting insulin analogues given subcutaneously, which in studies have shown better postprandial glucose control and less tendency to nocturnal hypoglycaemia.2 3 A Cochrane review of randomised controlled trials comparing inhaled with injected short acting unmodified human insulin used for prandial insulin replacement, in conjunction with a basal injected insulin, concluded that inhaled insulin provided equivalent control to fully injected regimens.
But there were drawbacks in the insulin injection regimes (see paper)
In patients with type 2 diabetes, adding inhaled insulin to oral hypoglycaemic regimens does improve control more than doing nothing.5
The advantages of inhaled over injected insulins to date relate to patients' preferences. This is important—apart from patients' comfort, an expensive new insulin could have huge potential advantage if it encouraged adherence and resulted in more patients with diabetes achieving treatment targets. Sadly, the published data on patients' satisfaction, superficially encouraging, are difficult to interpret, as invariably patients have been comparing a new treatment with an old one. When a specially designed questionnaire was used, treatment satisfaction improved significantly in patients with type 1 and type 2 diabetes on taking part in the trials, irrespective of whether the mealtime insulins they took were injected or inhaled.6-8
Notably, improvement in treatment satisfaction correlated with improved glycaemic control. Might greater satisfaction have been obtained with injected regimens if these had been optimised effectively? Were the studies just too short to show the biomedical gains one might anticipate from a treatment expressly designed to support compliance, or do the problems of insulin therapy extend beyond a dislike of needles?
Inhaled insulin has potential problems. The bioavailability is affected by asthma (decreased) and smoking (increased).9 10 Of course, if patients really dislike injections so much inhaled insulin might make its biggest impact on complications of diabetes if it were to be available only to proved non-smokers. Formation of anti-insulin antibodies is higher with inhaled insulin, and although this is dismissed as not affecting insulin requirement over time, older diabetologists will remember the drive to reduce insulin antibody formation, with the fears that antibodies delay and render unpredictable insulin absorption and even that antibody-antigen complexes may increase risk of microvascular disease.11 Finally, there have been concerns about possible long term effects of insulin on lung structure and function, although current published trials report no deleterious effects over the short-term.
For patients with established type 1 diabetes lack of freedom to eat or not eat and the demand for (painful) blood glucose testing may be much more of an issue than injection therapy itself.12 In one study only 14% of injections were missed because they were injections.13 In this group healthcare providers will need more robust evidence of patients' preference than is currently available. Where inhaled insulins could really have an impact (in the developed world) will be if healthcare professionals and patients start to use insulin much earlier and more aggressively in type 2 diabetes, affecting the progression of diabetic complications. In the developing world, where cultural taboos against injection treatments may be even more real than here, inhaled insulin may be expected to deliver more in terms of health benefit—but is not likely to be more affordable or available than the currently inadequate supplies of injected insulin. Meanwhile, all patients are waiting to see if the new inhalations are safe. If they are, and if they are cheap enough, at least one barrier to better diabetes treatment may fall.
comment: at last a new way of administering insulin which may be more pateint friendly. But there are potential problems.
BMJ 2004;328:1214-1215 (22 May), doi:10.1136/bmj.328.7450.1214
Vulval vestibulitis
Is a common and poorly recognised cause of dyspareunia
Vulval vestibulitis or vestibulodynia is one of the vulval pain syndromes and is characterised by burning and soreness at the vaginal introitus at attempted penetration
It is found predominantly in young, well educated, white women. Although the prevalence is unknown, a recent, as yet unpublished, survey in community settings in west Hertfordshire shows a prevalence of 2.8-9.3%. The diagnosis is based on a triad of findings—penetrative pain, introital tenderness, and patchy erythema localised to the orifices of the vestibular glands in the absence of an infective, inflammatory, or neoplastic cause.1 The burning nature of the pain is typical of dysaesthesia, and many patients go on to develop more persistent and generalised vulval pain that would be compatible with dysaesthetic vulvodynia, a condition classically found in older women. The pain of vulval vestibulitis should be distinguished from vulval pruritus, which has different causes.
The cause of the condition is unknown, attempts to identify an infective cause have been unsuccessful, and no characteristic histological findings are known.2 The subtlety of the physical findings may lead some clinicians to say that "there is nothing wrong" and attribute the symptoms to a psychosomatic disorder.
Once the condition is recognised, the patient is best referred to a specialist vulval clinic. Different local arrangements pertain in the United Kingdom, some clinics being multidisciplinary and some led by dermatologists, gynaecologists, or genitourinary physicians. Since the cause of the condition is poorly understood, management is largely pragmatic and several models of care exist. The evidence base for treatment is poor.
Glazer et al have proposed that the condition is caused by a dysfunction of the pelvic floor muscles and have published impressive results for a biofeedback technique.10 Many patients do have pelvic floor dysfunction, but in some cases this seems to be secondary to the pain. Low dose amitriptyline is the treatment of choice for dysaesthetic vulvodynia and may be useful in some patients, particularly when the pain is not restricted to attempted vaginal penetration.11 In North America, vestibulectomy, a procedure that involves excision of all or part of the vestibule, has been a popular treatment. Bergeron et al have reviewed 20 published case series and note that impressive results have been obtained, but the lack of controlled studies or long term follow up throws considerable doubt on the validity of the conclusions.12 In the United Kingdom, this procedure is rarely used.
Whatever therapeutic approach is adopted, the psychological, interpersonal, sexual, and social consequences of the condition need to be assessed. Every clinician managing patients with the condition should have access to a psychologist or psychotherapist with experience of managing sexual dysfunctions in individuals and couples. Many patients find that support from other patients may be helpful. In the United Kingdom, the Vulval Pain Society (www.vul-pain.dircon.co.uk) provides a useful handbook for patients, as does the US National Vulvodynia Association (www.nva.com).
Comment: poorly recognised but very few clinics to refer to. Need for easier accesss to these clinics
Vulval vestibulitis
Is a common and poorly recognised cause of dyspareunia
Vulval vestibulitis or vestibulodynia is one of the vulval pain syndromes and is characterised by burning and soreness at the vaginal introitus at attempted penetration
It is found predominantly in young, well educated, white women. Although the prevalence is unknown, a recent, as yet unpublished, survey in community settings in west Hertfordshire shows a prevalence of 2.8-9.3%. The diagnosis is based on a triad of findings—penetrative pain, introital tenderness, and patchy erythema localised to the orifices of the vestibular glands in the absence of an infective, inflammatory, or neoplastic cause.1 The burning nature of the pain is typical of dysaesthesia, and many patients go on to develop more persistent and generalised vulval pain that would be compatible with dysaesthetic vulvodynia, a condition classically found in older women. The pain of vulval vestibulitis should be distinguished from vulval pruritus, which has different causes.
The cause of the condition is unknown, attempts to identify an infective cause have been unsuccessful, and no characteristic histological findings are known.2 The subtlety of the physical findings may lead some clinicians to say that "there is nothing wrong" and attribute the symptoms to a psychosomatic disorder.
Once the condition is recognised, the patient is best referred to a specialist vulval clinic. Different local arrangements pertain in the United Kingdom, some clinics being multidisciplinary and some led by dermatologists, gynaecologists, or genitourinary physicians. Since the cause of the condition is poorly understood, management is largely pragmatic and several models of care exist. The evidence base for treatment is poor.
Glazer et al have proposed that the condition is caused by a dysfunction of the pelvic floor muscles and have published impressive results for a biofeedback technique.10 Many patients do have pelvic floor dysfunction, but in some cases this seems to be secondary to the pain. Low dose amitriptyline is the treatment of choice for dysaesthetic vulvodynia and may be useful in some patients, particularly when the pain is not restricted to attempted vaginal penetration.11 In North America, vestibulectomy, a procedure that involves excision of all or part of the vestibule, has been a popular treatment. Bergeron et al have reviewed 20 published case series and note that impressive results have been obtained, but the lack of controlled studies or long term follow up throws considerable doubt on the validity of the conclusions.12 In the United Kingdom, this procedure is rarely used.
Whatever therapeutic approach is adopted, the psychological, interpersonal, sexual, and social consequences of the condition need to be assessed. Every clinician managing patients with the condition should have access to a psychologist or psychotherapist with experience of managing sexual dysfunctions in individuals and couples. Many patients find that support from other patients may be helpful. In the United Kingdom, the Vulval Pain Society (www.vul-pain.dircon.co.uk) provides a useful handbook for patients, as does the US National Vulvodynia Association (www.nva.com).
Comment: poorly recognised but very few clinics to refer to. Need for easier accesss to these clinics
BMJ 2004;328:1240 (22 May), doi:10.1136/bmj.328.7450.1240
Review of instruments for peer assessment of physicians
Richard Evans, clinical research fellow1, Glyn Elwyn, professor1, Adrian Edwards, reader1
Comment: just shows how difficult peer assesment is and with the new appraisal/revalidation system it brings the question of how is the best way to assess our peers.
Review of instruments for peer assessment of physicians
Richard Evans, clinical research fellow1, Glyn Elwyn, professor1, Adrian Edwards, reader1
Comment: just shows how difficult peer assesment is and with the new appraisal/revalidation system it brings the question of how is the best way to assess our peers.
BMJ 2004;328 (22 May), doi:10.1136/bmj.328.7450.0-e
School education programmes can reduce obesity
A simple educational programme delivered to children can help tackle obesity. James and colleagues (p 1237) randomised 644 children aged 7-11 to a one hour session of advice on healthy drinking, or to no intervention. After one year, children in the intervention group were drinking 0.6 fewer glasses of carbonate drinks over three days (p = 0.02), but those in the control group were drinking 0.2 glasses more (p = n.s.). The percentage of overweight and obese children increased in the control group by 7.5% and decreased in the intervention group by 0.2%, mean difference 7.7% (CI 2.2 to 13.1).
School education programmes can reduce obesity
A simple educational programme delivered to children can help tackle obesity. James and colleagues (p 1237) randomised 644 children aged 7-11 to a one hour session of advice on healthy drinking, or to no intervention. After one year, children in the intervention group were drinking 0.6 fewer glasses of carbonate drinks over three days (p = 0.02), but those in the control group were drinking 0.2 glasses more (p = n.s.). The percentage of overweight and obese children increased in the control group by 7.5% and decreased in the intervention group by 0.2%, mean difference 7.7% (CI 2.2 to 13.1).
BMJ 2004;328 (22 May), doi:10.1136/bmj.328.7450.0-c
Simple mortality data may be misleading...
League tables, ranking hospitals by death rates, may not adequately represent the quality of care provided. Outcomes after subarachnoid haemorrhage were significantly different between Nottingham and Newcastle (unfavoraurable outcome 15% v 35%) between 1992 and 1998, report Mitchell and colleagues (p 1234). These differences disappeared when the effect of age and presenting conditions was included. Using crude results to guide clinical governance and policy making would have been pernicious, say the authors.
Comment: just as I suspected, league tables can be misleading!
Simple mortality data may be misleading...
League tables, ranking hospitals by death rates, may not adequately represent the quality of care provided. Outcomes after subarachnoid haemorrhage were significantly different between Nottingham and Newcastle (unfavoraurable outcome 15% v 35%) between 1992 and 1998, report Mitchell and colleagues (p 1234). These differences disappeared when the effect of age and presenting conditions was included. Using crude results to guide clinical governance and policy making would have been pernicious, say the authors.
Comment: just as I suspected, league tables can be misleading!
BMJ 2004;328 (22 May), doi:10.1136/bmj.328.7450.0
Infections increase the risk of atopic dermatitis
Infectious diseases in the first six months of life increase the risk of atopic dermatitis. Analysing 24 341 mother-child pairs, Benn and colleagues (p 1223) found that the risk of atopic dermatitis increased with each infectious disease, and decreased with exposure to siblings, day care, pet ownership, and farm residence. These findings challenge the hygiene hypothesis, which holds that infectious diseases protect against allergic diseases. Better hygiene decreases the production of regulatory T cells, resulting in the emergence of allergies, says Watts in a commentary (p 1226); preliminary attempts at vaccination are based on stimulating the production of these T cells.
Comment: evidence is conflicting in this area, but ?do day care/other sibs increase likelihood of infectious diseases, ?confounding factors
Infections increase the risk of atopic dermatitis
Infectious diseases in the first six months of life increase the risk of atopic dermatitis. Analysing 24 341 mother-child pairs, Benn and colleagues (p 1223) found that the risk of atopic dermatitis increased with each infectious disease, and decreased with exposure to siblings, day care, pet ownership, and farm residence. These findings challenge the hygiene hypothesis, which holds that infectious diseases protect against allergic diseases. Better hygiene decreases the production of regulatory T cells, resulting in the emergence of allergies, says Watts in a commentary (p 1226); preliminary attempts at vaccination are based on stimulating the production of these T cells.
Comment: evidence is conflicting in this area, but ?do day care/other sibs increase likelihood of infectious diseases, ?confounding factors
Friday, May 14, 2004
BMJ 2004;328:1187 (15 May), doi:10.1136/bmj.328.7449.1187
The door handle sign
She had been to see me several times during the previous few months with a variety of minor and seemingly insignificant symptoms. This occasion was no different; she had a minor degree of hallux valgus, a runny nose, and some contact dermatitis on her wrist. She was, however, clearly very unhappy, but I could not discover an underlying cause. After a long and unsatisfactory consultation, she left my consulting room leaving me aware that I had failed to meet her need. Fortunately, as she closed the door behind her, I noticed that the handle continued to turn unnecessarily two or three times.
I followed her into the by now crowded waiting room and asked her to come back. "I think there is something you haven't told me," I said. Immediately she burst into tears and started to undo her dress. Her chest was swathed in purulent bandages, which covered a gangrenous breast carcinoma en cuirasse.
The relief was immediate and enormous. I don't know how she had managed to conceal this from her husband for so long. I don't think my failure to make a full examination on her first visit would have altered the prognosis, but it was a salutary lesson not to write off every seeming hypochondriac. Despite the dire situation, my subsequent consultations and visits were very rewarding.
Comment;
go with your gut feeling and do not be afraid of being blunt!
The door handle sign
She had been to see me several times during the previous few months with a variety of minor and seemingly insignificant symptoms. This occasion was no different; she had a minor degree of hallux valgus, a runny nose, and some contact dermatitis on her wrist. She was, however, clearly very unhappy, but I could not discover an underlying cause. After a long and unsatisfactory consultation, she left my consulting room leaving me aware that I had failed to meet her need. Fortunately, as she closed the door behind her, I noticed that the handle continued to turn unnecessarily two or three times.
I followed her into the by now crowded waiting room and asked her to come back. "I think there is something you haven't told me," I said. Immediately she burst into tears and started to undo her dress. Her chest was swathed in purulent bandages, which covered a gangrenous breast carcinoma en cuirasse.
The relief was immediate and enormous. I don't know how she had managed to conceal this from her husband for so long. I don't think my failure to make a full examination on her first visit would have altered the prognosis, but it was a salutary lesson not to write off every seeming hypochondriac. Despite the dire situation, my subsequent consultations and visits were very rewarding.
Comment;
go with your gut feeling and do not be afraid of being blunt!
BMJ 2004;328:1184-1187 (15 May), doi:10.1136/bmj.328.7449.1184
The clinician's perspective on electronic health records and how they can affect patient care
comment
Good article going through the various methods and ways in which we use computer today. Some solutions to problems also.
The clinician's perspective on electronic health records and how they can affect patient care
comment
Good article going through the various methods and ways in which we use computer today. Some solutions to problems also.
BMJ 2004;328:1095 (8 May), doi:10.1136/bmj.328.7448.1095-a
Patients with type 2 diabetes should take statins
New York Scott Gottlieb
Most patients with type 2 diabetes should take statins to help prevent heart disease, whether or not they have high cholesterol concentrations, new guidelines say.
The recommendations, from the American College of Physicians, call for moderate doses of statins for people with diabetes who are older than 55 and for younger patients who have any other risk factor for heart disease, such as high blood pressure or a history of smoking (Annals of Internal Medicine 2004;140:644-9). The guidelines are based on the results of six studies of primary prevention and eight trials of secondary prevention in patients with diabetes.
Given the markedly elevated risk for cardiovascular events in most persons with type 2 diabetes, preventing cardiovascular disease through aggressive management of cardiovascular risk factors is of utmost importance," the guidelines say. "The evidence suggests that lipid-lowering medication leads to a 22% to 24% reduction in major cardiovascular events in patients with diabetes. On the basis of the current literature, statins are the agents of choice."
The guidelines call for lipid lowering drugs to be used for secondary prevention of cardiovascular mortality and morbidity in all patients with known coronary artery disease and type 2 diabetes and for primary prevention against macrovascular complications in patients with type 2 diabetes and other cardiovascular risk factors.
For patients with type 2 diabetes who are taking statins, routine monitoring of liver function tests or muscle enzymes is not recommended except in specific circumstances.
Dr Vijan said the new guidelines called for moderate doses of statins. The largest clinical trial involving patients with diabetes used a dose of 40 mg of simvastatin. He said researchers were evaluating recently published studies that indicated that high doses of statins might have better results.
Comment:
All diabetics should be on a statin if can tolerate.
Patients with type 2 diabetes should take statins
New York Scott Gottlieb
Most patients with type 2 diabetes should take statins to help prevent heart disease, whether or not they have high cholesterol concentrations, new guidelines say.
The recommendations, from the American College of Physicians, call for moderate doses of statins for people with diabetes who are older than 55 and for younger patients who have any other risk factor for heart disease, such as high blood pressure or a history of smoking (Annals of Internal Medicine 2004;140:644-9). The guidelines are based on the results of six studies of primary prevention and eight trials of secondary prevention in patients with diabetes.
Given the markedly elevated risk for cardiovascular events in most persons with type 2 diabetes, preventing cardiovascular disease through aggressive management of cardiovascular risk factors is of utmost importance," the guidelines say. "The evidence suggests that lipid-lowering medication leads to a 22% to 24% reduction in major cardiovascular events in patients with diabetes. On the basis of the current literature, statins are the agents of choice."
The guidelines call for lipid lowering drugs to be used for secondary prevention of cardiovascular mortality and morbidity in all patients with known coronary artery disease and type 2 diabetes and for primary prevention against macrovascular complications in patients with type 2 diabetes and other cardiovascular risk factors.
For patients with type 2 diabetes who are taking statins, routine monitoring of liver function tests or muscle enzymes is not recommended except in specific circumstances.
Dr Vijan said the new guidelines called for moderate doses of statins. The largest clinical trial involving patients with diabetes used a dose of 40 mg of simvastatin. He said researchers were evaluating recently published studies that indicated that high doses of statins might have better results.
Comment:
All diabetics should be on a statin if can tolerate.
BMJ 2004;328:1093 (8 May), doi:10.1136/bmj.328.7448.1093
Newer hypnotics no better for insomnia than short acting benzodiazepines
The National Institute for Clinical Excellence (NICE) has issued new guidance to the NHS recommending that hypnotic drugs be used for severe insomnia only for short periods and only after non-pharmacological measures have been considered.
Non-pharmacological treatments include cognitive behaviour therapy and relaxation techniques and avoiding stimulants (such as coffee) before bedtime.
NICE does not distinguish between newer hypnotics known as Z drugs (zaleplon, zolpidem, and zopiclone) and short acting benzodiazepines such as loprazolam, lorazepam, lormetazepam and temazepam—recommending that the drug with the "lowest purchase cost" be chosen.
NICE's appraisal committee came to its decision after finding no compelling evidence of a clinically useful difference between the Z drugs and short acting benzodiazepines in terms of effectiveness, adverse effects, or potential for misuse or dependence.
The guidance is expected to provide cost savings to the NHS, with a possible reduction in the prescribing of hypnotics. NICE notes that in 2002 the NHS spent £15.9m ($28.2m; 23.6m) on Z drugs.
However, the guidance does not have the support of the British Sleep Society, a professional organisation for medical and scientific staff who deal with sleep disorders.
The society's representative, David Nutt, professor of psychopharmacology and head of the department of community based medicine at the University of Bristol, said that it was not sensible of NICE to recommend "short acting" benzodiazepines as hypnotics as they are not actually short acting.
For example, lorazepam has an average half life of about 15 hours, meaning it will have significant effects on the brain for at least two half lives (30 hours) after administration, he said. He believes that loprazolam, lormetazepam, and temazepam, which have medium half lives (between eight and 13 hours), will also result in next day effects in many people.
The society told NICE that only drugs with a half life of less than four hours (such as zolpidem and zaleplon) are short acting enough to be considered likely to be free of significant carryover effects the next day. Professor Nutt said that it seems perverse that patients will be forced to run the risk of significant daytime hangover to save a few pence on drug costs. He said pressure will be put on clinicians as a result of the guidance not to use Z drugs.
The society made an appeal against the guidance, but this was rejected by NICE. This is because there were no grounds for appeal, NICE said.
NICE also recommends that hypnotics be prescribed in strict accordance with their licensed indications and that drugs should be switched only if the patient experiences side effects specifically related to that medicine.
Comment
This needs public attention and very difficult not to prescibe when under pressure from patient, also what about the pateints prescribed them in secondary care esp from psychiatry, v difficult to wean off once they are on it.
Newer hypnotics no better for insomnia than short acting benzodiazepines
The National Institute for Clinical Excellence (NICE) has issued new guidance to the NHS recommending that hypnotic drugs be used for severe insomnia only for short periods and only after non-pharmacological measures have been considered.
Non-pharmacological treatments include cognitive behaviour therapy and relaxation techniques and avoiding stimulants (such as coffee) before bedtime.
NICE does not distinguish between newer hypnotics known as Z drugs (zaleplon, zolpidem, and zopiclone) and short acting benzodiazepines such as loprazolam, lorazepam, lormetazepam and temazepam—recommending that the drug with the "lowest purchase cost" be chosen.
NICE's appraisal committee came to its decision after finding no compelling evidence of a clinically useful difference between the Z drugs and short acting benzodiazepines in terms of effectiveness, adverse effects, or potential for misuse or dependence.
The guidance is expected to provide cost savings to the NHS, with a possible reduction in the prescribing of hypnotics. NICE notes that in 2002 the NHS spent £15.9m ($28.2m; 23.6m) on Z drugs.
However, the guidance does not have the support of the British Sleep Society, a professional organisation for medical and scientific staff who deal with sleep disorders.
The society's representative, David Nutt, professor of psychopharmacology and head of the department of community based medicine at the University of Bristol, said that it was not sensible of NICE to recommend "short acting" benzodiazepines as hypnotics as they are not actually short acting.
For example, lorazepam has an average half life of about 15 hours, meaning it will have significant effects on the brain for at least two half lives (30 hours) after administration, he said. He believes that loprazolam, lormetazepam, and temazepam, which have medium half lives (between eight and 13 hours), will also result in next day effects in many people.
The society told NICE that only drugs with a half life of less than four hours (such as zolpidem and zaleplon) are short acting enough to be considered likely to be free of significant carryover effects the next day. Professor Nutt said that it seems perverse that patients will be forced to run the risk of significant daytime hangover to save a few pence on drug costs. He said pressure will be put on clinicians as a result of the guidance not to use Z drugs.
The society made an appeal against the guidance, but this was rejected by NICE. This is because there were no grounds for appeal, NICE said.
NICE also recommends that hypnotics be prescribed in strict accordance with their licensed indications and that drugs should be switched only if the patient experiences side effects specifically related to that medicine.
Comment
This needs public attention and very difficult not to prescibe when under pressure from patient, also what about the pateints prescribed them in secondary care esp from psychiatry, v difficult to wean off once they are on it.
BMJ 2004;328:1089-1090 (8 May), doi:10.1136/bmj.328.7448.1089
Physical activity and coronary heart disease
Fifty years of research confirms inverse relationship
Fifty years ago the first empirical investigation of what was subsequently termed the exercise hypothesis—physical activity reduces the occurrence of coronary heart disease—was undertaken by Morris et al.1 Using data from two cohorts of British workers, they reported lower rates of coronary heart disease in bus conductors than in less occupationally active bus drivers, and in postmen relative to deskbound telephonists and other office based employees.
We still do not fully understand the pathways underlying the protective effect of physical exertion against coronary heart disease. In addition to well established improvements in blood pressure, lipid profile, insulin sensitivity, and body weight, activity may improve endothelial function and coronary blood flow and may be associated with beneficial changes in haemostatic and inflammatory variables.5 6 These warrant further examination. Given the public's reluctance to be physically active, future research also needs to identify the minimum dose (the total volume of activity, as well as the intensity, duration, and frequency), type (aerobic, strength training), and mode (walking, swimming) of activity associated with reduced coronary heart disease risk that will be most palatable to the sedentary populations. For the prevention of a range of chronic diseases, including coronary heart disease, the current recommendation is 30 minutes or more of moderately intense aerobic activity such as brisk walking or cycling on five or more occasions per week.7 Worryingly, however, the prevalence of activity in most Western societies does not match this: in England, for example, only about one quarter of men and women currently achieve this level,8 and these figures are lower still in elderly people.
Although the governments of many countries, including the United Kingdom, have the opportunities to implement such changes in urban form in order to make environments more conducive to physical activity, what they may lack is the political resolve. This may be short sighted. Given the high prevalence of sedentary behaviour and its association with a range of chronic diseases—which include not only coronary heart disease, but also stroke, type 2 diabetes, certain cancers, and osteoporotic fractures12—modification of physical activity may, as Morris indicated four decades after the publication of his seminal work, represent today's best buy in public health.13
Comment:
Get those pedometers out and get moving! difficult to motivate a culture that is deskbound.
Physical activity and coronary heart disease
Fifty years of research confirms inverse relationship
Fifty years ago the first empirical investigation of what was subsequently termed the exercise hypothesis—physical activity reduces the occurrence of coronary heart disease—was undertaken by Morris et al.1 Using data from two cohorts of British workers, they reported lower rates of coronary heart disease in bus conductors than in less occupationally active bus drivers, and in postmen relative to deskbound telephonists and other office based employees.
We still do not fully understand the pathways underlying the protective effect of physical exertion against coronary heart disease. In addition to well established improvements in blood pressure, lipid profile, insulin sensitivity, and body weight, activity may improve endothelial function and coronary blood flow and may be associated with beneficial changes in haemostatic and inflammatory variables.5 6 These warrant further examination. Given the public's reluctance to be physically active, future research also needs to identify the minimum dose (the total volume of activity, as well as the intensity, duration, and frequency), type (aerobic, strength training), and mode (walking, swimming) of activity associated with reduced coronary heart disease risk that will be most palatable to the sedentary populations. For the prevention of a range of chronic diseases, including coronary heart disease, the current recommendation is 30 minutes or more of moderately intense aerobic activity such as brisk walking or cycling on five or more occasions per week.7 Worryingly, however, the prevalence of activity in most Western societies does not match this: in England, for example, only about one quarter of men and women currently achieve this level,8 and these figures are lower still in elderly people.
Although the governments of many countries, including the United Kingdom, have the opportunities to implement such changes in urban form in order to make environments more conducive to physical activity, what they may lack is the political resolve. This may be short sighted. Given the high prevalence of sedentary behaviour and its association with a range of chronic diseases—which include not only coronary heart disease, but also stroke, type 2 diabetes, certain cancers, and osteoporotic fractures12—modification of physical activity may, as Morris indicated four decades after the publication of his seminal work, represent today's best buy in public health.13
Comment:
Get those pedometers out and get moving! difficult to motivate a culture that is deskbound.
BMJ 2004;328:1085-1086 (8 May), doi:10.1136/bmj.328.7448.1085
Informal care giving for disabled stroke survivors
Training the care giver benefits the patient, the care giver, and the community
At any time, about 0.5% of the population of the United Kingdom (250 000 out of 50 million) are disabled stroke survivors who are dependent on the help of a carer to perform community based activities (for example, shopping), domestic activities (housework), and personal activities of daily living (mobilising, toileting, bathing, dressing, grooming, and feeding).1 the onus of caring for such patients at home usually falls on one or more informal care givers, who are often family members (usually spouses and children), and sometimes friends.
Because of the prevalence and seriousness of the problem of caregiver burden and stress, several attempts have been made to devise, develop, and evaluate strategies of reducing the burden of informal care giving for dependent stroke survivors. These include the provision of information and education and access to services such as nursing, psychological counselling, emotional support, family support workers, and social workers.9-12 Although modest benefits have been realised in some measured emotional, psychological, and social outcomes, care givers have continued to be compromised by physical stress in particular.
Kalra et al have taken the next step and shown by means of a randomised controlled trial that supplementing information and emotional support for informal care givers with specific training in basic nursing skills such as moving and handling, and facilitation of activities of daily living improves the outcome of disabled stroke survivors, informal care givers, and the community.5 A higher proportion of disabled stroke survivors achieved independence at an earlier stage, the mood and quality of life of disabled stroke survivors and care givers were improved, and the cost of stroke care was reduced. Whether these results can be generalised beyond middle class suburban United Kingdom and care givers who are motivated, keen, and physically fit needs further study.
The implications of these results, if they can be generalised widely, are that the (inpatient and outpatient) rehabilitation and care of disabled stroke survivors should be broadened to include the proposed care giver in the multidisciplinary rehabilitation team, involving them actively in setting goals, rehabilitation, care, and planning discharge and ensuring they are as adequately trained, supported, and followed as the patient.13 Although healthcare business managers may baulk at the perceived additional costs of providing training services for carers, perhaps they can dip into the greater pool of funds that would otherwise be required to provide care in hostels and nursing homes and thus help improve the quality of life of disabled stroke survivors and their carers.
Comment: Carers do need more support and are an undervalued "NHS" resource. IT would be nice to think that they can rehabilitate stroke survivors but I think the editors comment about the population that was selected has a lot to do with improved outcome and may not be generalisable elsewhere.
Informal care giving for disabled stroke survivors
Training the care giver benefits the patient, the care giver, and the community
At any time, about 0.5% of the population of the United Kingdom (250 000 out of 50 million) are disabled stroke survivors who are dependent on the help of a carer to perform community based activities (for example, shopping), domestic activities (housework), and personal activities of daily living (mobilising, toileting, bathing, dressing, grooming, and feeding).1 the onus of caring for such patients at home usually falls on one or more informal care givers, who are often family members (usually spouses and children), and sometimes friends.
Because of the prevalence and seriousness of the problem of caregiver burden and stress, several attempts have been made to devise, develop, and evaluate strategies of reducing the burden of informal care giving for dependent stroke survivors. These include the provision of information and education and access to services such as nursing, psychological counselling, emotional support, family support workers, and social workers.9-12 Although modest benefits have been realised in some measured emotional, psychological, and social outcomes, care givers have continued to be compromised by physical stress in particular.
Kalra et al have taken the next step and shown by means of a randomised controlled trial that supplementing information and emotional support for informal care givers with specific training in basic nursing skills such as moving and handling, and facilitation of activities of daily living improves the outcome of disabled stroke survivors, informal care givers, and the community.5 A higher proportion of disabled stroke survivors achieved independence at an earlier stage, the mood and quality of life of disabled stroke survivors and care givers were improved, and the cost of stroke care was reduced. Whether these results can be generalised beyond middle class suburban United Kingdom and care givers who are motivated, keen, and physically fit needs further study.
The implications of these results, if they can be generalised widely, are that the (inpatient and outpatient) rehabilitation and care of disabled stroke survivors should be broadened to include the proposed care giver in the multidisciplinary rehabilitation team, involving them actively in setting goals, rehabilitation, care, and planning discharge and ensuring they are as adequately trained, supported, and followed as the patient.13 Although healthcare business managers may baulk at the perceived additional costs of providing training services for carers, perhaps they can dip into the greater pool of funds that would otherwise be required to provide care in hostels and nursing homes and thus help improve the quality of life of disabled stroke survivors and their carers.
Comment: Carers do need more support and are an undervalued "NHS" resource. IT would be nice to think that they can rehabilitate stroke survivors but I think the editors comment about the population that was selected has a lot to do with improved outcome and may not be generalisable elsewhere.
BMJ 2004;328 (8 May), doi:10.1136/bmj.328.7448.0-d
Poorer Scottish patients with heart failure see their GPs less
The risk of heart failure is higher among poorer people in Scotland, but poorer people are less likely to see their general practitioner than affluent patients. McAlister and colleagues (p 1110) identified 2186 patients with heart failure among 307 741 patients from 53 general practices participating in the Scottish continuous morbidity project between April 1999 and March 2000. They found that, compared with affluent patients, poorer patients were 44% more likely to develop heart failure but 23% less likely to have ongoing contact with their general practitioner. General practitioners' prescribing did not differ across different social classes. Socioeconomically deprived patient may have poorer outcomes because they have less contact with their general practitioners, conclude the authors.
Comment
this would go against what is usually known about healthcare. With poorer patients consulting more for healthcare.
Poorer Scottish patients with heart failure see their GPs less
The risk of heart failure is higher among poorer people in Scotland, but poorer people are less likely to see their general practitioner than affluent patients. McAlister and colleagues (p 1110) identified 2186 patients with heart failure among 307 741 patients from 53 general practices participating in the Scottish continuous morbidity project between April 1999 and March 2000. They found that, compared with affluent patients, poorer patients were 44% more likely to develop heart failure but 23% less likely to have ongoing contact with their general practitioner. General practitioners' prescribing did not differ across different social classes. Socioeconomically deprived patient may have poorer outcomes because they have less contact with their general practitioners, conclude the authors.
Comment
this would go against what is usually known about healthcare. With poorer patients consulting more for healthcare.
BMJ 2004;328 (8 May), doi:10.1136/bmj.328.7448.0-b
A third of type 1 diabetics have renal damage within 20 years
About a third of patients diagnosed as having type 1 diabetes will develop persistent microalbuminuria within 20 years. Of the 277 patients with newly diagnosed type 1 diabetes followed up by Hovind and colleagues (p 1105) for a median of 18 years, 79 developed persistent microalbuminuria and 27 progressed further to persistent macroalbuminuria. Higher urinary albumin excretion rate, higher systolic and diastolic blood pressure, lower stature, higher glycated haemoglobin concentration, and male sex were all predictors of microalbuminuria. Poor glycaemic control at the onset of diabetes is an important predictor of microalbuminuria, say the authors, and spontaneous permanent regression to normoalbuminuria is uncommon.
Comment
a lot of patients getting renal complications. Most predictors could have been guessed at, ?same to be said of type II. More evidence for tight glyceamic and BP control. ?why being male a predictor, ?sample too small ?the study population males were atypical
A third of type 1 diabetics have renal damage within 20 years
About a third of patients diagnosed as having type 1 diabetes will develop persistent microalbuminuria within 20 years. Of the 277 patients with newly diagnosed type 1 diabetes followed up by Hovind and colleagues (p 1105) for a median of 18 years, 79 developed persistent microalbuminuria and 27 progressed further to persistent macroalbuminuria. Higher urinary albumin excretion rate, higher systolic and diastolic blood pressure, lower stature, higher glycated haemoglobin concentration, and male sex were all predictors of microalbuminuria. Poor glycaemic control at the onset of diabetes is an important predictor of microalbuminuria, say the authors, and spontaneous permanent regression to normoalbuminuria is uncommon.
Comment
a lot of patients getting renal complications. Most predictors could have been guessed at, ?same to be said of type II. More evidence for tight glyceamic and BP control. ?why being male a predictor, ?sample too small ?the study population males were atypical
