This week in the BMJ
Volume 327, Number 7414, Issue of 6 Sep 2003Alcohol screening in general practice is not effective
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 improves intractable dyspnoea
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 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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Parathyroidectomy is better than conservative management
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.
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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 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.
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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
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. 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.
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