This week in the BMJ

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Louis Lasagna, the man who “created clinical pharmacology,” was clearly bold. His obituary describes how 50 years ago he injected saline subcutaneously into ...
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Alcohol screening in general practice is not effective Screening for excessive alcohol use and then providing brief interventions is not effective in general practice. Beich and colleagues (p 536) conducted a meta-analysis of eight studies that evaluated screening as a precursor for brief interventions and found that the number needed to be screened per success and the workload are impracticably high if the available evidence is transferred into daily practice. For every 1000 patients screened, only 2.6 would benefit. They say that good clinical practice for addressing lifestyle issues like drinking should focus on the communication challenge rather than on implementating screening programmes with low levels of effectiveness.

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Morphine can provide added relief to patients who have intractable breathlessness even though they are receiving maximal treatment for its underlying causes. In a randomised, double blind, placebo controlled, crossover study in 38 patients with predominantly chronic

Surgery No surgery

1.0 0.8 0.6 0.4 0.2 0 0

Morphine improves intractable dyspnoea

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Parathyroidectomy is better than conservative management


10 15 20 Years from diagnosis

Patients who undergo surgery for primary hyperparathyroidism have fewer fractures and gastroduodenal ulcers than those treated conservatively. Vestergaard and Mosekilde (p 530) studied more than 3000 Danish patients diagnosed between 1980 and 1999 as having primary hyperparathryroidism. They found that patients treated surgically had a 30% lower risk of fractures and a 40% lower risk of stomach and duodenal ulcers, and lived longer. Surgery was not associated with a lower risk of cardiovascular events.

Heart failure is more common but has better prognosis in South Asian patients Rates of admission to hospital for heart failure are higher among South Asian people than the indigenous white population in the United Kingdom. Blackledge and


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This week in the BMJ


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obstructive pulmonary disease, Abernethy and colleagues (p 523) showed that 20 mg of sustained release morphine daily improved dyspnoea scores by 7-10%, without respiratory depression or serious side effects. The authors state that the use of opioids in the management of intractable breathlessness has been controversial.


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colleagues (p 526) conducted a historical cohort study of 14 797 events for admission to hospital between 1998 and 2001. Admission and incidence rates were up to four times higher in South Asian patients than in white patients. At first admission for heart failure, South Asians were on average eight years younger than white patients and were more likely to have coronary heart disease and diabetes. Despite major differences in risk factors, survival outcomes are similar, if not better, among South Asian patients, the authors say.

Prehospital life support in trauma patients should be questioned Prehospital staff may not be able to master the skills needed to provide advanced life support in severely injured patients. In an observational study of 741 trauma cases in Aarhus, Denmark during 1998 to 2000, Christensen and colleagues (p 533) describe severely injured patients who were intubated out of hospital with and without anaesthetic drugs. Prehospital intubation took place in 43% of severely injured patients, most of whom received anaesthetics. More than half of the patients who received anaesthetics survived 6 months. Eight per cent of patients intubated without drugs survived. The authors state that the evidence for providing advanced prehospital life support for trauma patients is still lacking.

Patient involvement in healthcare decisions is hard on doctors BSIP/LAURENT/SPL

Doctors are encouraged to involve patients in making treatment decisions, but this poses challenges for doctors. In a clinical review article, Say and Thomson (p 542) discuss these challenges, which include the extra time and effort required to elicit patients’ perspectives and the negotiations needed when the preferences of the doctor and the patient differ.

Editor’s choice Be bold and be sensible

Doctors often do not have the interpersonal skills to sufficiently communicate risk. A dearth of appropriate information to support patients’ treatment decisions is also a problem, say the authors.

POEM* Warming diptheria-tetanus vaccines doesn’t reduce pain Question Does warming diphtheria-tetanus vaccine reduce the discomfort of the injection? Synopsis Many healthcare providers warm the phials containing diphtheria-tetanus vaccine before injection to reduce pain and side effects. A convenience sample of 150 patients aged 16 years or older cared for in an emergency department who required a diphtheria-tetanus booster vaccination was identified. Subjects were randomly assigned in a double blind fashion (concealed allocation assignment) to receive a vaccine that had been given no deliberate warming (“cold”); rubbed for one minute between a nurse’s hands (“rubbed”); or placed in a 37°C warming cupboard for five minutes (“warmed”). The temperature of the liquid in the syringe was measured with a flux wire temperature probe immediately before injection. All outcomes were assessed five minutes after injection and at 24 and 48 hours by individuals blind to treatment group assignment. A total of 92% of the patients were available for complete follow up. With intention to treat analysis, no significant differences between the vaccine groups in the incidence of pain or the number of adverse reactions after injection were noted at any of the follow up evaluations. Interestingly, the temperature of the vaccines immediately before injection approached ambient temperature in all three groups, most likely secondary to the large surface area of the syringe relative to the small amount of fluid (0.5 ml). I would have liked the authors to have evaluated the pain immediately after injection to see if there was any difference between the groups. Bottom line Warming the adult diphtheria-tetanus vaccine either by rubbing in the hands or with a warmer does not reduce the incidence of pain or adverse reactions after injection. Although the study was done only on adults, there is no reason to assume that warming is beneficial for children. Level of evidence 1b (see levels.html); individual randomised controlled trials (with narrow confidence interval). Maiden MJ, Benton GN, Bourne RA. Effect of warming adult diphtheria-tetanus vaccine on discomfort after injection: a randomised controlled trial. Med J Aust 2003;178:433-6.

“Fortune assists the bold,” wrote Virgil, thinking of the Trojan wars not of medicine. But there is room for boldness in medicine, and I see examples in this BMJ. The Global Initiative on Chronic Obstructive Lung Disease—a pretentiously named outfit that must have slavered over its acronym GOLD and which is backed by the National Institutes of Health and the World Health Organization—warns against using opioids in managing patients with dyspnoea and chronic obstructive pulmonary disease (p 523). We all know that opioids are respiratory depressants and that such patients have almost no respiratory reserve. Yet some experienced doctors believe that morphine can help patients with refractory dyspnoea. A bold group from Australia has now conducted an adequately powered crossover trial of oral morphine against placebo in patients with refractory dyspnoea in whom the underlying aetiology is maximally treated (p 523). The morphine produced important improvements. The authors think that the results are generalisable to primary, respiratory, and palliative care settings but warn that a bigger study is needed to evaluate safety. Louis Lasagna, the man who “created clinical pharmacology,” was clearly bold. His obituary describes how 50 years ago he injected saline subcutaneously into surgical patients with steady, severe wound pain and found that roughly a third reported satisfactory relief of pain (p 565). It was essential, he argued, to consider the placebo response in clinical trials. England’s National Institute of Clinical Excellence (NICE) seems to be getting bolder, perhaps because its chairman, Mike Rawlins, is also getting bolder. For years he was chairman of the Committee on Safety of Medicines, but at a recent meeting he was dismissive of what he described as its traditional method of a lot of old boys sitting round a table and issuing instructions. It’s too paternalistic. A better method might be to give people clear information and let them make up their own minds. NICE has now decided that in vitro fertilisation works and should be available on the National Health Service (p 511). We didn’t need NICE to tell us that in vitro fertilisation works, but the idea that it should be available to all subfertile couples is bold. Most such couples have had to go to the private sector to get treatment. The cost of treating all couples would be hundreds of millions of pounds each year, meaning that treatments for other patients would have to be denied. Unfortunately it’s not NICE’s job to tell the NHS what should be ditched to free up the millions needed, but it does offer some guidance on treatments that shouldn’t be used—strictly on the evidence. Thus it last week advised against the use of thiazolidinediones (glitazones) in patients with type 2 diabetes except in narrow circumstances (p 520). Diabetes UK immediately leapt in and condemned the advice as “rationing.” NICE should be bold enough never to fear “the r word” that politicians don’t dare to speak. Richard Smith editor [email protected]

©infoPOEMs 1992-2003 * Patient-Oriented Evidence that Matters. See editorial (BMJ 2002;325:983)



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