This week in the BMJ
Volume 327, Number 7422, Issue of 1 Nov 2003Advance directives are open to different interpretations
Advance directives are open to different interpretations
When confronted with an advance directive, doctors take different actions. Thompson and colleagues (p 1011) presented clinicians with a hypothetical vignette of a demented patient who becomes ill with pneumonia requiring antibiotic treatment. The advance directive was interpreted differently by the interviewees, resulting in different treatments. The authors say this results from ambiguous terminology.
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Outreach teams may improve care of critically ill patients
Critical care outreach teams seem to improve in-hospital survival after discharge from critical care and may decrease patients' readmission rate to intensive care units. Ball and colleagues (p 1014) retrospectively analysed data of 470 patients from a north London hospital and found a significant increase in survival and decrease in readmission to critical care after an outreach team was introduced. They conclude that outreach teams may improve patient management, but more robust evidence is needed before their widespread introduction.
Fewer trials supported by non-commercial funders
The number of randomised controlled trials supported by the main non-commercial funding sources is declining. Chalmers and colleagues (p 1017) surveyed 1464 randomised controlled trials in the United Kingdom funded between 1980 and 2002 by the Medical Research Council, the NHS, and medical research charities. The number of trials funded by non-commercial sources decreased continually in the past few years. The authors call for a coherent strategy to ensure support of trials that are of great interest to patients and practitioners but of no interest to the industry.
Multidrug therapy has reduced death and illness in HIV infected children
Since the introduction of potent anti-HIV drugs in 1997 the risk of death, progression to AIDS, and hospital admission in children with perinatally acquired HIV have decreased substantially in the United Kingdom and Ireland. Gibb and colleagues (p 1019) report results from the national study of HIV in pregnancy and childhood (NSHPC) and the collaborative HIV paediatric study (CHIPS) cohort on nearly 1000 children under clinical care between the late 1980s and 2002. Since the mid-1990s the transmission of HIV from mothers to babies has reduced, but the number of children under care is increasing and they are becoming older. The total number of admissions has fallen by only a quarter since 1996, which has implications for service development.
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Suicide is related to spouse's mental health
Spouses of people who have a severe psychiatric disorder are at increased risk of suicide. In a case-control study, Agerbo (p 1025) examined 9011 suicides from Denmark and found that the risk of committing suicide was higher if a spouse had been admitted to hospital with a psychiatric disorder or had died, particularly from suicide.
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Clinical research is dying in the United Kingdom
Clinical research is going through hard times. In our Education and Debate section John Bell (p 1041) analyses the current status of research in the United Kingdom. After a golden era during the 1970s, a shift towards laboratory and molecular research has reduced the number of clinical trials. Lack of funding, facilities, and trained scientists; medicolegal issues; and inconsistent use of opportunities in the NHS are affecting the ability to deliver good clinical research. Three accompanying editorials show that the way forward is through revitalising academic medicine. Clark and Smith (p 1001) launch a campaign to promote academic medicine, Bhutta (p 1000) provides a perspective from the developing world, and Stewart (p 999) calls for immediate action in the United Kingdom, where the NHS trusts are assessed mainly by clinical performance with no mention of research.
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