This week in the BMJ

Volume 326, Number 7384, Issue of 8 Feb 2003

[Down]High risk of HIV infection during remand in Thailand
[Down]Communication with seriously ill children is challenging
[Down]Decision support systems disrupt GPs' workflow
[Down]Cardiac troponin T is raised in severe pulmonary embolism
[Down]Competent in evidence based medicine? Take the Fresno test
[Down]TSH is a poor measure of severity of tissue hypothyroidism

High risk of HIV infection during remand in Thailand

Injecting drug users in Bangkok, Thailand, are at high risk of HIV infection in police holding cells before incarceration because of sharing needles with multiple partners. Buavirat and colleagues (p 308) studied 347 male injecting drug users and investigated the associations between HIV infection and sexual and parenteral exposure before, during, and after their most recent incarceration. Other factors associated with HIV infection were injection of methamphetamine before incarceration, being tattooed while in prison, and sharing needles after release. Risk of infection may be higher because of the symptoms of severe opiate withdrawal experienced during the transitional period before incarceration.
 
(Credit: EMMANUEL DUNAND-STF/AFP)




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Communication with seriously ill children is challenging

Parents assume an executive role when their children are seriously ill. Young and colleagues (p 305) interviewed 13 children with cancer and 19 parents and found that parents actively managed communication by withholding, delaying, or diluting information. This was particularly evident at the time of diagnosis. The executive role, usually tacitly endorsed by health professionals, hampered open communication with young people and left some feeling marginalised. Health professionals face a challenge in balancing the sometimes conflicting priorities and needs of children with cancer and their parents.



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Decision support systems disrupt GPs' workflow

General practitioners and nurses find computerised decision support systems for chronic disease management difficult and unhelpful. Rousseau and colleagues (p 314) conducted a qualitative interview study in parallel with a randomised controlled trial of a decision support system for the management of stable angina and asthma in primary care (BMJ 2002;325:941)[Abstract/Free Full Text]. Clinicians reported that the system triggered at inappropriate times, was difficult to use despite training, lacked individualised guidance for patients, and did not add to their current knowledge. It did not fit well within a general practice consultation, which suggests much more work is needed to improve the utility and acceptability of computerised decision supports.
 
(Credit: VICTOR HABBICK VISIONS/SPL)




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Cardiac troponin T is raised in severe pulmonary embolism

Case reports and small series show that concentrations of cardiac troponin T are sometimes raised in patients with acute pulmonary embolism, probably indicating right ventricular strain. In a retrospective cohort study of 106 patients with acute pulmonary embolism, Janata and colleagues (p 312) found that cardiac troponin T concentrations were associated with increased clinical severity, electrocardiographic and echocardiographic signs of right ventricular strain, and higher mortality in hospital. Measurement of cardiac troponin T may be useful in medical decision making---for example, about whether to administer thrombolytic treatment.



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Competent in evidence based medicine? Take the Fresno test

The Fresno test, named for the California city in which it originated and the first test designed to assess all domains of evidence based practice, is both reliable and valid. Ramos and colleagues (p 319) developed and then validated the Fresno test using a sample of 96 novice and expert candidates. The short questionnaire had strong inter-rater reliability and clearly distinguished novices from experts. Doctors are increasingly expected to use research to inform their practice, but few evaluative tools exist to see how well these concepts are learned. Ideally, further validation would link performance to an objective assessment of patient care.
 
(Credit: JACK HUTCHESON/PHOTONICA)




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TSH is a poor measure of severity of tissue hypothyroidism

Thyroid stimulating hormone (TSH) tests are not useful for estimating the clinical and metabolic severity of primary overt thyroid failure. Meier and colleagues (p 311) found that, in contrast with the accuracy of serum TSH measurement in the early diagnosis of hypothyroidism, clinical markers and circulating thyroid hormones much more accurately reflect the degree of tissue hypothyroidism. Initiation of replacement therapy should be guided by clinical presentation and circulating thyroid hormones and not by TSH concentrations, a point discussed in an editorial by Toft and Beckett (p 295).



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