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US Highlights
Here are items from recent BMJ issues that may
be of particular interest to American readers. Happy reading. Comments welcome. |
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US editor’s choice September 30 In this week’s issue, a large Danish trial finds that children born to previously infertile couples are more likely to have congenital malformations than children of fertile parents, irrespective of whether the couples received infertility treatment. Zhu and colleagues followed up 61 249 singletons and 3156 twins and their mothers within the national birth cohort for a median of four years from the time of birth. It’s not clear whether hormone treatment for infertility increases the risk of malformations or if this association is confounded by the underlying reason for infertility, the authors say. Park and colleagues, in an accompanying editorial, recommend further research into the underlying mechanisms of these associations and provision of improved risk assessment and counseling services for couples. Copious literature examines the bullying and harassment of medical students, but how common is it? Erica Frank and colleagues conducted a longitudinal survey among 2884 students in the class of 2003 at 16 US medical schools. Altogether 2316 students responded; 42% of senior students reported having experienced harassment, and 84% reported belittlement during medical school, by other students, residents, professors, and patients. Although few students characterized these incidents as severe, poor mental health and low career satisfaction were significantly correlated with these experiences. Rates of bullying are much lower among UK students, probably because of cultural differences, as Diana Wood points out in an accompanying editorial. In view of the severe negative effect that bullying and harassment have in the workplace, continuing efforts are needed for seniors to moderate their behavior so that they become positive role models. And some challenges obviously only start after medical school. In his personal view, psychiatrist Arnob Chakraborti considers whether it is appropriate to disclose personal details to patients, as a means of showing empathy in a therapeutic relationship. On discussing the issue with his trainers, he was advised to use his discretion. Although self disclosure or even tactile assurance may be seen as minor matters—presumably by both parties—the author admits that the boundary between doctors’ personal and professional identities is not watertight. He concludes: “I wonder how important it is to get this aspect of the therapeutic relationship right; it is so easy to get it wrong.” This week's US Highlights were compiled by Birte Twisselmann, assistant editor (web). September 23 Whether acupuncture is helpful in chronic pain conditions is an ongoing debate. KJ Thomas and colleagues performed a randomized controlled trial of 10 acupuncture treatments over three months in 241 adults with persistent non-specific low back pain. Control patients received usual care, including medications, back exercises, physical therapy and/or manipulation. After 24 months, there was reasonably strong evidence of a small effect of the acupuncture group v placebo. In an accompanying economic analysis, J Ratcliffe et al calculated that acupuncture was a cost effective intervention, comparing favourably to other interventions in cost per quality adjusted life year. David Wonderling points out in an editorial that low back pain now joins migraine in being shown to be treated cost effectively with acupuncture. Bad breath (halitosis) is a common complaint. S Porter and C Scully review the causes and treatment of halitosis. By far the most common cause is poor oral hygiene. Regular dental care and brushing, with perhaps tongue cleaning in resistant cases, usually eliminates the problem. Nasal or sinus disease can sometimes lead to halitosis, which may diagnosed by separately noting that the bad smell emanates from the nose and not the mouth. If a bad smell comes from both the mouth and nose, a drug or systemic illness may be the cause. Finally, in a patient’s journey piece, Stuart Baker-Brown describes his battle with paranoid schizophrenia. It began on a visit to the former Soviet Union in 1991, and delusions about the KGB pursuing him persisted when he returned the UK. It was not until 2002 that he was taking medicine that he felt was appropriate. Baker-Brown gives a moving perspective of the difficulties of living with schizophrenia and interacting with the medical system. September 16 Emergency contraception, or the "morning after pill," is big news in the US, with over the counter dispensing recently approved by the FDA after a long, public battle. Anna Glasier asks in an editorial whether it was worth all the fuss, as emergency contraception hasn’t really been proven to decrease abortion rates, as its proponents claim. She concedes that it prevents pregnancy in some women, but as a dramatic public health intervention it is a failure. Lawrence Appel applauds the American Medical Association for its recent advocacy of dietary salt reduction in processed and “fast” foods. The AMA policy focuses attention on a dietary factor that, by causing or exacerbating hypertension, is clearly a population health threat. Salt is, however, backed by a strong political lobby that has thwarted previous attempts to decrease the salt content of prepared and restaurant foods. Reducing salt intake is hard to do in a world where much supermarket and restaurant food has high salt levels, so regulation may be necessary. Accurate detection of non-cephalic presentations in pregnancy just before term improves clinical outcomes and helps keep costs down. Natasha Nassar and colleagues in Australia compared clinical presentation assessments with ultrasound results in 1633 pregnant women at 35 to 37 weeks gestation. They found that the clinical examination was not a very sensitive predictor of non-cephalic presentation and advocate a cost-effectiveness analysis of routine ultrasounds near the end of pregnancy. In a related editorial, James Nicholson supports routine sonography at least for women whose clinicians aren’t experienced and confident of their clinical examination. The length of the needle used in infant immunizations varies with individual practice. Linda Diggle et al performed a randomized controlled trial of almost 600 British infants, comparing different needle sizes and the local reactions and immune response they caused. They found significantly fewer local reactions when one-inch needles were used instead of shorter ones, with no decrease in immunogenicity. Richard Zimmerman agrees in an editorial that using a one-inch needle would cause fewer local reactions, which in turn might decrease parental fears about vaccine side effects and thus increase vaccination rates. September 9 Compliance with multidrug regimens is a problem for people with chronic diseases. Jennifer Wu and colleagues from Hong Kong performed a randomized trial of pharmacist telephone counseling in between doctor visits in 500 non-compliant patients taking five or more drugs. After two years, those who received the pharmacist calls were more compliant, used less health care resources, and had less mortality. Although the intervention could not be blinded and thus the health care teams knew who was getting the counseling, the results argue for the importance of close follow-up of patients with chronic diseases taking multiple drugs. As patients age, their doctors become less aggressive in working up their symptoms and referring them for surgery. Sometimes this is appropriate, due to lower survival rates or patient preference. But for carotid endarterectomy, there is reasonably good evidence that the elderly benefit from surgery. Jack Fairhead and Peter Rothwell studied community referral rates for investigation and surgery of elderly patients after stroke and transient ischemic attack and compared them with those in the Oxford vascular study. They found significant underinvestigation and undertreatment, especially in those age 80 and over. In an accompanying editorial, John Young points out that part of the problem is insufficient resources, leading to rationing. But part of the blame must also be placed on the primary care doctors. DJ Humes and J Simpson review the diagnosis and treatment of acute appendicitis. Despite advances in imaging, the diagnosis remains largely clinical. Ultrasound, in the proper hands, and computed tomography can be helpful, but some experts recommend them only when the clinical and laboratory examinations are inconclusive. Appendicitis is most difficult to diagnose at the extremes of the age spectrum. Finally, primary care treatment of benign prostatic hyperplasia is reviewed by Anand Patel and Christopher Chapple. Improvement in symptoms can be attained quickly using α-antagonists such as alfuzosin and tamsulosin, although they do not affect prostate size or PSA levels. 5-α reductase inhibitors, such as finasteride and dutasteride, take six months to work but do decrease prostate volume and slow disease progression. Recent studies indicate that combining these two classes of medications may provide the most effective slowing of BPH progression. September 2 How do you treat patients with a minor head injury and a history of loss of consciousness? Admit to hospital for observation, do a computed tomography (CT) scan, or both? Jean-Luc af Geijerstam et al studied this common clinical problem in a randomized trial with over 2500 patients in 39 Swedish hospitals. They found that clinical outcomes were no worse and perhaps a bit better in the immediate CT scan group than in the group who were admitted to hospital for observation without an immediate scan. In an accompanying cost analysis, Anders Norlund and colleagues found that the immediate CT scan strategy was more cost effective. In a related editorial, BMJ editor and pediatrician Harvey Marcovitch discusses the results for children included in this trial, pointing out that there are probably savings—both economic and emotional—if children and families can be spared unnecessary overnight observations in neurology wards. Growing pains are a common problem that is not well defined. It is generally a diagnosis of exclusion in children 3-12 years old, explain Felicity Goodyear-Smith and Bruce Arroll. The pains usually present as bilateral non-articular aches that occur at night, with no positive physical or laboratory findings. Acetaminophen (paracetamol) and rest are the recommended treatments. What should we advise parents to do to protect their unborn children from allergies? In a 10-minute consultation, Chantelle Anandan and Aziz Sheikh recommend breast feeding, fish oil supplements, a smoke free environment, and exclusion of cow’s milk for six months as reasonable steps to take. They also debunk some of the myths about the causes of allergies. Finally, it seems that “Epi-pens” are ubiquitous around children these days, mainly in parents’ and children’s bags and backpacks to prevent anaphylaxis from food allergy. Allan Colver and Jonathan Hourihane debate whether food allergies are being overdiagnosed and overtreated. Colver maintains that the number of severe illnesses and deaths due to food allergy is extremely small, and all these autoinjectors are creating anxiety rather than protection. Hourihane counters that food allergies are common and delaying treatment can have serious consequences.
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September 30
Congenital anomalies
after treatment for infertility
Infertility, infertility
treatment, and congenital malformations: Danish national birth cohort
Experiences of
belittlement and harassment and their correlates among medical students
in the United States: longitudinal study
Personal view: “Did you
ever suffer from any mental illness?”
September 23
Randomised controlled trial of a short
course of traditional acupuncture compared with usual care for
persistent non-specific low back pain
A randomised controlled trial of
acupuncture care for persistent low back pain: cost effectiveness
analysis
Oral malodour (halitosis)
A patient’s journey: living with paranoid
schizophrenia
September 16
Salt reduction in the United States
Non-cephalic presentation in late pregnancy
Size of the needle for infant vaccination
Effect of needle size on immunogenicity and
reactogenicity of vaccines in infants: randomized controlled trial
Diagnostic accuracy of clinical examination
for detection of non-cephalic presentation in late pregnancy: cross
sectional analytic study
September 9
Effectiveness of telephone counselling by a pharmacist in reducing
mortality in patients
receiving polypharmacy: randomised
controlled trial
Underinvestigation and undertreatment of
carotid disease in elderly patients with transient ischaemic attack and
stroke: comparative population based study
Acute appendicitis
Benign prostatic hyperplasia: treatment in
primary care
September 2
Growing pains
Medical outcome after
immediate computed tomography or admission for observation in patients
with mild head injury: randomised controlled trial
Cost comparison of
immediate computed tomography or admission for observation after mild
head injury: randomised controlled trial
Preventing development
of allergic disorders in children
Are the dangers of
childhood food allergy exaggerated?
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