This week in the BMJ
Volume 328, Number 7447, Issue of 1 May 2004Don't expect too much from Viagra
Don't expect too much from Viagra
The expectations of patients taking sildenafil (Viagra) are high, and the higher the expectation the more extreme is the disappointment with failure. Tomlinson and Wright (p 1037) interviewed 40 men who had been prescribed sildenafil for erectile dysfunction. They found that the emotional and social ramifications of impotence were greater than expected: impotence carried a sense of emasculation and a decline in confidence, and affected the participants' relationship with their partners, friends, and work colleagues. Failure of treatment caused some patients additional anguish; for many, it confirmed their lack of self worth. Less sensational media reporting of the benefits of sildenafil would have lowered expectations, to the patients' benefit, say the authors.
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New search strategies retrieve morefrom Medline
New search strategies in Medline can optimise retrieval of high quality clinical studies on diagnostic tests. Haynes and colleagues (p 1040) analysed the sensitivity, specificity, precision, and accuracy of 17 287 multiple term search strategies and compared them against manual searching of journals published in 2000. The newly developed strategies retrieved up to 99% of scientifically strong studies on diagnostic tests and performed consistently better than strategies developed in 1991. The new strategies are now integrated into various databases, and can be freely accessed at http://web.ncbi.nlm.nih.gov/entrez/query/static/clinical.shtml or through other Medline suppliers.
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Scotland and London have widest health gap
The 2001 census documents a social and geographical health divide in Great Britain. Using the new government social class scheme (NS-SeC), Doran and colleagues (p 1043) examined data on 25.6 million people aged between 25 and 64, collected in the 2001 census of England, Wales, and Scotland. They found that rates of poor health increased from class 1 (higher professional occupations) to class 7 (routine occupations). People in all social classes living in Wales and in the north east and north west regions of England had higher rates of poor health than the rest of the population. The widest health gap between social classes was in Scotland and London, and women generally had poorer health than men, except when they were in class 6 (semi-routine occupations).
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Evidence on standard treatment of hepatic encephalopathy is uncertain
Non-absorbable disaccharides (lactulose and lactitol) are considered the treatment of choice for hepatic encephalopathy, but evidence neither supports nor refutes their use. Analysing 22 trials including 898 patients with hepatic encephalopathy, Als-Nielsen and colleagues (p 1046) found that patients taking lactulose and lactilol had the same mortality, but lower blood ammonia concentrations, than those who took placebo or had no intervention. They were more likely to show no improvement than those taking antibiotics, but whether this difference is clinically important is unclear. Non-absorbable disaccharides should not serve as comparator in randomised trials on hepatic encephalopathy, say the authors, until their effect is established.
Brief lifestyle interventions do not reduce blood pressure
In patients with a single high blood pressure reading, simple strategies to modify lifestyle have no effect on the control of blood pressure. Little and colleagues (p 1054) randomised 296 patients with a single high reading to combinations of simple interventions—an information booklet, lifestyle prompts, and advice to use a low sodium-high potassium salt—or standard care. The interventions did not modify blood pressure but they did prompt patients to change their diet, which may be important in the overall management of blood pressure.
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Patients with unexplained symptoms do not push for treatment
Patients with unexplained symptoms do not directly ask for an intervention, but they may pressurise general practitioners for somatic management in other ways. In a qualitative study of 36 consultations with patients with medically unexplained symptoms, Ring and colleagues (p 1057) found that, even though no patient asked for investigation or medical referral, most patients received interventions {prescriptions, investigations, or referrals). Patients presented their symptoms in a variety of complex and compelling ways, perhaps in the attempt to engage their doctors and convey the reality of their suffering. Doctors might have felt pressured for somatic interventions because they mistook patients' insistence as a desire for intervention or because they lacked another response to evident suffering, say the authors.
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