This week in the BMJ
Volume 326, Number 7392, Issue of 5 Apr 2003New cervical smear tests should not replace conventional ones
New cervical smear tests should not replace conventional ones
In cervical cancer screening, conventional smears are better than the new and more expensive technology. In a cross sectional study Coste and colleagues (p 733) evaluated the slides of 2585 women in terms of low and high grade lesions, and in populations with a low or a high incidence of abnormalities. They found that conventional smear tests were more reliable and had fewer false positives and negatives than liquid-based monolayer testing. Human papillomavirus testing associated with monolayer cytology, whether systematic or for diagnosis of atypical cells of undetermined significance, also proved no better than conventional smear testing. The authors conclude that replacement of conventional smear tests with monolayer cytology in countries such as the United States and Switzerland should be reconsidered.
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| (Credit: VT CYTOPATHOLOGY LAB) |
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Prevalence of H pylori is lower in patients with reflux disease
Patients with gastro-oesophageal reflux disease have a lower
prevalence of Helicobacter pylori infection than patients
without this disease. Raghunath and colleagues (p 737) conducted a
systematic review of the medical literature and contacted experts and
pharmaceutical companies, and identified 20 studies. On average,
H pylori infection was present in 39% of patients with
reflux disease and in 50% of the patients without the
disease. Location seems to be another important determinant:
the prevalence of H pylori infection in patients with
reflux disease is much lower in the Far East, despite a higher
prevalence in the general population, than in North America and western Europe.
Participation in teaching is good therapy for patients with mental disorders
Patients with common mental disorders benefit from participation in undergraduate teaching in primary care. Walters and colleagues (p 740) surveyed patients and conducted in depth interviews with patients, general practitioner tutors, and students involved in undergraduate psychiatry teaching in primary care. Over 90% of the patients reported satisfaction with teaching encounters. The interviews revealed specific therapeutic benefits for patients, such as increased self esteem and empowerment, improved understanding of their feelings, and new insights into their problems. Patients valued the time to talk and reflect, and some patients and doctors reported a stronger doctor-patient relationship. For a few patients participation caused some distress, which should be evaluated in a larger sample.
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| (Credit: PHANIE/REX) |
Healthcare quality programmes lack evidence
Little evidence exists that large scale programmes to improve the
quality of health care bring important benefits or are worth the cost.
In the first of three articles on research to improve the quality of
health care, Øvretveit and Gustafson (p 759) describe research
designs that have proved successful in evaluating quality programmes
and highlight common failures of previous studies. Because these
quality programmes involve dynamic organisations and change over time,
the authors emphasise that their effectiveness is difficult to evaluate.
How to treat herpes zoster and postherpetic neuralgia
Herpes zoster requires treatment to manage acute symptoms and reduce the risk of long term complications. Johnson and colleagues (p 748) discuss the treatment options of herpes zoster infection (shingles) and suggest that most cases can be handled in primary care. They advocate the use of antiviral drugs in the acute stage of shingles to reduce the risk of prolonged pain, particularly for patients aged 50 or more and for immunocompromised patients. In patients with postherpetic neuralgia, treatment includes more than one drug, but they also need advice on psychosocial issues. For example, keeping up with physical and social activities should be encouraged, as well as wearing natural fibre clothing. If effective pain control is not achieved, primary care providers should refer patients to specialist care.
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| (Credit: CNRI/SPL) |
Work based assessment is best for appraisal of doctors
Assessing clinical competence is becoming routine and is valuable and
feasible. Norcini (p 753) explains what is meant by work based
assessment for doctors and presents a classification scheme of current
methods. Making judgments about the quality of a doctor's performance
involves an assessment of patients' outcomes, processes of care, and
the volume of practice. Various data made available for clinical audit
can be used to assist with appraisal of doctors. Norcini argues that
work based assessments are better reflections of performance than those
done under test conditions.
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