This week in the BMJ
Volume 325, Number 7376, Issue of 7 Dec 2002Nurses can carry out preoperative assessment
Nurses can carry out preoperative assessment
Appropriately trained nurses are no worse than preregistration
house officers in assessing patients before elective surgery. In a
randomised controlled trial Kinley and colleagues (p 1323) compared
preoperative assessment carried out by nurses with that carried out by
house officers. They found few differences in history taken and
physical examinations, but house officers ordered substantially more
unnecessary tests, which has economic implications. Reforms in
postgraduate medical training and the introduction of reduced working
hours have increased pressure to substitute non-medical staff for
preregistration house officers. The authors conclude that there is no
contraindication to the development of nurse led preoperative
assessment, although house officers will have to continue to undertake
some of the work to satisfy training requirements.
(Credit: PHANIE/REX)
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Bacterial vaginosis is not a strong risk factor for early miscarriage
Bacterial vaginosis is not a strong risk factor for miscarriage
before 16 weeks' gestation, but it may be associated with miscarriage
in the second trimester. Oakeshott and colleagues (p 1334) conducted a
prospective cohort study of 1216 pregnant women attending general
practices and family planning clinics. Although treatment of
asymptomatic bacterial vaginosis is unlikely to prevent miscarriage in
the first trimester, initiatives to prevent miscarriage in the second
trimester and preterm birth should consider screening and treatment
before 13 weeks' gestation. Non-invasive screening for bacterial
vaginosis by using self-administered vaginal swaps is feasible in
community based, healthy pregnant women.
Participants may never know which arm of the trial they were in
Less than half of investigators inform participants about their
treatment allocation at the end of a trial. Di Blasi and colleagues (p 1329) surveyed more than 200 investigators of placebo controlled clinical trials published in five leading medical journals in 2000 or
registered in the national research register. Overall, 40% of
investigators had never considered informing participants. Nearly a
quarter of investigators were worried that disclosure would bias
results at follow up of the study. These findings challenge a recent
report from the Department of Health stating that once research
findings are established, principal investigators must feed back
findings to participants or their representatives. More effective and
sensitive ways of communicating treatment allocation to participants
are needed, as well as information on the effects on placebo
responders.
Doctors overlook living wills
In patients with advanced dementia, doctors' decisions to withhold the
artificial administration of fluids and food are based more on the
medical condition of the patient, the family's wishes, and care
providers' interpretations of the patient's quality of life than they
are on living wills and policy agreements. In an ethnographic study,
The and colleagues (p 1326) studied the practice of withholding the
artificial administration of fluids and food from patients with
advanced dementia in two nursing homes in the Netherlands. Fluids and
food were mainly given artificially when there was an acute illness or
a condition that needed medical treatment and required hydration to be
effective. When faced with uncertainties about what the patient wanted,
doctors tried to create the broadest possible basis for the decision
making process by involving the family.
(Credit: LEHTIKUVA OY/REX)
Short courses in evidence based medicine can work
Short courses in evidence based medicine can lead to a clinically
relevant increase in knowledge and skills, which is a prerequisite for
evidence based practice. In a three year study among
postgraduate doctors in Germany, Fritsche and
colleagues (p 1338) investigated the effectiveness of teaching
evidence based medicine. Using a specifically developed
and validated instrument, they confirmed a short term change in
knowledge and skills. The instrument reliably distinguished knowledge
and skills between groups with different levels of expertise. Recent
reviews, mostly based on low quality studies, had queried the benefit
of short courses in evidence based medicine.
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