This week in the BMJ
Volume 328, Number 7434, Issue of 31 Jan 2004Triple therapy is the best treatment for some HIV patients
Triple therapy is the best treatment for some HIV patients
Triple regimens with protease inhibitors may be superior to regimens based on non-nucleoside reverse transcriptase inhibitors and to two nucleoside reverse transcriptase inhibitor regimens in adults with advanced HIV infection. In a systematic review and indirect meta-analysis, Yazdanpanah and colleagues (p 249) analysed data on 6785 patients included in 14 trials, comparing triple and dual therapy for HIV infection. They found that, in patients with advanced disease who had been exposed to nucleoside reverse transcriptase inhibitors, protease inhibitor based triple regimens are superior to other treatment for preventing progression to AIDS or death.
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Vignettes make self reported questionnaire comparable
Interpretation of self reported measures of health may be improved by methods that account for different expectations of health across individuals, communities, and populations. Salomon and colleagues (p 258) report on a new approach using anchoring vignettes linked to self assessment, which aims to detect and adjust for differences in expectations between individuals. They found that vignettes may help identify differences in health expectation across age groups and countries, and may make self reports more comparable.
Internet education can alleviate depression
Increased knowledge and cognitive behaviour therapy can be delivered by the internet and can alleviate symptoms of depression. Christensen and colleagues (p 265) randomised 525 people with depression to a website offering information about depression or one offering cognitive behaviour therapy, or to an attention placebo consisting of weekly contact with a lay interviewer. They found that after six weeks, cognitive behaviour therapy delivered by the internet reduced dysfunctional thinking and depressive symptoms, and psychoeducation reduced symptoms and increased knowledge of effective treatment for depression. The authors conclude that the internet could be a powerful tool for delivering public health interventions.
Acute chest pain? Better go to a chest pain unit
Care in a chest pain observation unit improves outcomes and may reduce costs to the health service. Goodacre and collagues (p 254) randomised 972 patients who presented with acute undifferentiated chest pain either to care delivered in a chest observation unit or to routine care. Fewer patients who went to the chest pain unit were admitted to hospital and were discharged with acute coronary syndrome, but the proportion with cardiac events was the same. The saving per patient in the chest pain unit was £78, and health utility was improved.
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Singletons but not twins are at risk after assisted conception
Singleton pregnancies after assisted reproduction have a worse perinatal outcome than non-assisted pregnancies, but in twins perinatal mortality is lower after assisted conception. Reviewing 25 studies comparing assisted and non-assisted pregnancies, Helmerhorst and colleagues (p 261) found that after assisted conception mortality was much higher in singleton pregnancies, but it was 40% lower in twin pregnancies. Assisted conception carried a higher risk of preterm deliveries and more risk of caesarean section and admission to neonatal intensive care, and 40% more infants were small for gestational age. A quarter century after the first birth of a baby conceived by in vitro fertilisation, the focus has to shift from how to achieve pregnancy to how to achieve a successful outcome, the authors say.
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Simulation of medical emergencies improves patients' care
On-site simulation of rare emergencies may improve the management of real patients without exposing them to inadequate care. Thompson and colleagues (p 269) report on a fire drill programme, using on-site simulation, to evacuate patients with eclampsia. They recorded the action of staff in written and video format during the drills, and identified problems with activation of the team, use of protocols, individual skills, drug usage, time wasting, and staff coordination. The authors developed and implemented solutions that resulted in improved care of simulated patients in subsequent drills, applying evidence based management and enhancing the level of efficiency.
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