This week in the BMJ
Volume 328, Number 7440, Issue of 13 Mar 2004Variations in end of life care
Variations in end of life care
The utilisation of end of life care varies widely among the "best" hospitals in the United States. Wennberg and colleagues (p 607) analysed how often doctors saw patients, how long patients stayed in hospital on average, how long they stayed in intensive care units, and what proportion went to hospices at the end of their lives. Their cohort consisted of patients treated in 77 hospitals included in the 2001 US News and World Report "best hospital" list. They found great variations in end of life care, attributable to a greater availability of facilities. In an accompanying commentary (p 610), Hunter raises concerns about the English NHS Plan, which plans to increase doctors and the number of beds but would not guarantee that better health would result.
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It was not a phaeochromocytoma
In hypertensive patients, the combination of increased catecholamine concentration, and a positive radiolabelled catecholamine uptake scan, in the site of an adrenal mass support the diagnosis of phaeochromocytoma. But this is not always the case, as our lesson of the week by Zendrom and colleagues (p 629) shows. The combination of an adrenal adenoma and a dilated renal pelvis in a patient taking levodopa and carbidopa, led to the mistake. A correct diagnosis of phaeochromocytoma depends on looking critically at diagnostic tests, careful anatomical and functional examination, and thorough history taking, including history of drugs.
Intrathecal antitetanus treatment works better
Patients treated with combined intrathecal and intramuscular injections of antitetanus immunoglobulin improve more quickly than those treated by the intramuscular route alone. De Barros and colleagues (p 615) randomised 120 patients with tetanus to receive antitetanus immunoglobulin by the combined intrathecal and intramuscular route or by the intramuscular route alone. They found patients responded better, spasms were shorter, and less respiratory assistance was needed in the intervention group.
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Children treated for heart conditions survive equally well across UK
Survival after paediatric cardiac surgery or therapeutic catheterisation is equal in 13 congenital heart disease centres in the United Kingdom. Gibbs and colleagues (p 611) analysed data from the central cardiac audit database for 2000-1 and found that results of individual centres and operators did not differ from the national average. Survival at one year was double than that at 30 days, and may be a better descriptor of overall outcome. When individual centres' data were broken down into distinct types of treatment, numbers became small, and risk stratification has yet to be developed. Independent validation of data is essential for accurate analysis, the authors say.
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How do general practitioners manage domestic violence?
General practitioners identify and manage partner abuse in various ways, and often lack expertise to treat these patients and their families. Taft and colleagues (p 618) interviewed 28 Australian general practitioners who attended training on management of domestic violence. They found that a few doctors practised in recommended ways, some used contraindicated practices, and many were uneasy about treating victims of intimate partner abuse and concerned about the optimal care of their children. The authors emphasise existing good practice and argue that more GPs should use recommended guidelines, refrain from counselling couples, emphasise safety and confidentiality, and refer to specialised agencies.
Abuse from a partner may contribute to depression
Physical, emotional, and sexual abuse are associated with depression in women. Hegarty and colleagues (p 621) interviewed 1257 women from Australia who were attending 30 general practice surgeries in Victoria. They found that 18% were currently depressed, and 24% had experienced some type of abuse in an adult intimate relationship. Depressed women were more likely to have experienced some form of abuse as a child, and to have experienced partner abuse, than women who were not depressed. Doctors should consider the role of past or current violence and abuse in their depressed women patients, the authors say.
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