US Highlights

Here are items from recent BMJ issues that may be of particular interest to American readers. Happy reading. Comments welcome.

Douglas Kamerow
US editor

US editor’s choice

July 29

Randomized controlled trials are still uncommon in surgery, but they are starting to appear with regularity in general medical journals. This week we learn in a Dutch study by Niels Kok and colleagues that patients undergoing laparoscopic donor nephrectomy have better quality of life after surgery than those having open surgery with a “mini incision.” Laparoscopic surgery takes longer but results in less blood loss. Clinical outcomes for the resulting kidney donation were the same in both groups. In a related editorial, Nick Townell emphasizes the importance of fully informing potential donors of the risks of this type of surgery and insuring that they are not pressured into consenting to it.

Antipsychotic drugs have revolutionized the care of patients with schizophrenia, and newer drugs always promise, but don’t always deliver, improved outcomes. Jari Tiihonen and associates studied the outcomes of over 2000 adults with schizophrenia in Finland. Most importantly, they found that these patients needed to be on antipsychotic drugs; mortality was markedly raised in those not taking them. Outcomes also differed depending on which drugs were being taken, not always correlating with whether the drugs were newer antipsychotics. Some older drugs were just as effective. In an accompanying editorial, David Kingdon discusses other research that has found that cognitive and psychological therapies are also helpful in schizophrenia, although they are much harder to deliver than pills.

In a methodological analysis of 260 recently published research studies, Peter Gøtzsche found that many papers’ significance statistics are inaccurate, especially those found in the abstract sections. Most of the significance levels hover around—but are almost always less than—the magical 0.05 level. He warns us not to believe significance results reported in abstracts.

Finally, Christopher Whitty et al review the treatment of adults with malaria in non-endemic countries. Since most malaria treatment trials have been performed in endemic areas with patients who already have some antibodies to the disease, published treatment efficacy may be overestimated in non-endemic areas. Malaria is a common disease and should be thought of immediately in patients who are unwell after returning from travel to malarial regions. They recommend initial inpatient treatment for all patients with falciparum malaria, even if they are receiving oral medication only.

July 22

Most American doctors who care for women may not know that vaginal speculum examinations in the UK are generally performed on women whose feet are not up in stirrups. Dean Seehusen and staff doctors from a US Army base in Georgia performed a randomized controlled trial comparing pelvic exams with and without stirrups. They found that women who had the exams without stirrups reported significantly less vulnerability and discomfort. There was no significant difference in Pap smear sample quality obtained in the two different positions.

In an accompanying commentary, British doctors Pippa Oakeshott and Phillip Hay state that this article should change practice in the US. American family physician Wendy Barr is not so sure, asking in an editorial for more information about the stirrup-less exam and better evidence that sample quality is not compromised. A training video for the exam without stirrups is available on bmj.com.

Trevor Brooklyn and associates review the diagnosis and treatment of pyoderma gangrenosum. This rare skin lesion usually presents as a deep ulcer and is seen about half of the time in patients with chronic conditions or cancers. Biopsy is necessary to exclude other diagnoses, and treatment is with corticosteroids or immunosuppressants such as cyclosporine.

Finally, an obituary in this issue remembers American bioethicist and neurologist Ronald Cranford, who helped define persistent vegetative state and became internationally known as one of Terry Schiavo’s physicians.

July 15

Generally we in the US think of female genital mutilation as a distant problem. In an editorial commenting on a paper on the topic from Africa in this issue, Ronán Conroy points out that a form of female genital mutilation is on the increase in the US and other developed societies. “Laser vaginal rejuvenation” and other similarly named procedures are apparently a growth area in plastic surgery. They are performed to make the vagina tighter and the vulva more childlike. They fit the World Health Organization definition of female genital mutilation.

Cataract surgery is the most common surgical procedure in the developed world, and David Allen and Abhay Vasavada review its indications and techniques. There are no definitive indications for intraocular lens replacement; basically cataracts should come out when the patient’s function has deteriorated to a point where the benefit exceeds the very slight risks associated with the surgery. Simply visualizing a cataract in an asymptomatic patient is not a reason for referral for surgery. New techniques have made smaller and smaller incisions possible, and now only a 2mm incision is required to implant a modern foldable lens. In the developed world, surgical complications are rare, although refractive outcome may not always turn out as expected. Unlike in the US, in the developing world cataracts remain the largest cause of blindness. Less sophisticated techniques are commonly used because of the lack of trained surgeons and modern equipment.

Drug safety is often not well understood or communicated. R Ferner and J Aronson provide a thoughtful discussion of drug harms as well as proposing a new way to communicate those harms to doctors and patients. They point out that evidence is often lacking on drug harms, whether they are adverse drug reactions, drug-drug interactions, or contraindications. They also discuss the types of studies that are needed to establish harm. If their suggestions were followed, drug manuals would be clearer and everyone would be better informed.

July 8

This issue of the BMJ has several papers on preventing car crash injuries. In an accompanying editorial, Shanthi Ameratunga and colleagues summarize the take-home messages from this research: despite the progress use of car seats has made in reducing child car crash fatalities, death rates in children in the poorest families have been relatively unaffected; drivers are largely flouting prohibitions of hand-held cell phone use while driving; and driver sleepiness, even acknowledged sleepiness, is associated with a three-fold increased risk of serious injury from car crashes. All of these would seem to be instructive for primary care doctors’ counseling around auto safety. 

Because poor glycemic control in diabetes is often associated with depression and other psychological problems, much research has evaluated psychological interventions to improve diabetic control. Kirsty Winkley et al performed a systematic review and meta-analysis of randomized controlled trials to assess the effectiveness of these interventions. They found a significant but small benefit in studies in children and adolescents, with family therapy seeming to be the most effective strategy. In adults, there was no evidence of benefit in glycemic control for the various psychological interventions that were tested.

A common dilemma in primary care is what to do with patients who present with painless rectal bleeding. Jennifer du Toit and colleagues from a British general practice evaluated all such patients aged 45 or older for a ten year period and summarized their results. A total of 265 patients presented with new rectal bleeding. Almost six percent were found to have colon cancer and another five percent had adenomas. In total, around 10 percent of patients 45 or older with new rectal bleeding had neoplasia of some sort, enough to justify workups for everyone. In an accompanying editorial, David Weller confirms the importance of these workups, even in patients without other bowel complaints, but also reminds practitioners to screen patients routinely. Most colorectal cancers do not present with rectal bleeding.  

July 1

Questionnaires that address patient satisfaction and perceived quality of care are increasingly common. Some studies show that they are valid measures when compared to gold standards. Mala Rao and associates compared the results of general practice questionnaires completed by almost 3500 patients in England aged 65 or older with three measures of care quality independently collected. There was poor correlation. The authors conclude that older patients’ assessments are not a sufficient measure of physicians’ technical capabilities. In an accompanying editorial, Angela Coulter points out that there are at least two aspects to care: technical quality and communication skills. Patients aren’t very good at rating the former, but their opinions about the latter can be valid and useful.

Ole Norheim comments on a UK issue that has importance in the US as well: what is the role of patient consent in the linking of medical record data? The UK National Health Service is embarking on a nationwide system that will connect medical record databases, an important initiative that will likely improve patient care and outcomes but is accompanied by concerns about privacy. One question is whether patients should first give consent to be enrolled in the national system (so called “opt-in”) or be enrolled unless they refuse to participate (“opt-out”). Norheim argues that the opt-out position is ethically defensible because of the societal good that would result. It is an debate that we will no doubt see more of in the US.

A common question in child health care is whether to give the two major antipyretics—acetaminophen (called paracetamol in the UK) and ibuprofen—together, either simultaneously or alternately. Alistair Hay et al briefly review the scant literature on this topic and find little support that combined therapy is any better than single therapy or, for that matter, than physical cooling measures. While they don’t recommend against using the two drugs together, they do urge caution.

Finally, Cheryl Healton and associates look at the co-occurrence of two important risk factors in the US population: cigarette smoking and obesity. Their analysis finds that these two risk factors occur together in slightly less than 5% of the US population. As one would expect, this group is disproportionately drawn from people with low socioeconomic status. It is a point worth remembering in the clinical setting.

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