This week in the BMJ
Volume 328, Number 7454, Issue of 19 Jun 2004Steroids do not prevent long term nerve damage in leprosy
Steroids do not prevent long term nerve damage in leprosy
Giving prednisolone to patients with leprosy does not prevent long term nerve damage. Smith and colleagues (p 1459) randomised 635 people with newly diagnosed multibacillary leprosy from Bangladesh and Nepal to prophylaxis with low dose prednisolone (20 mg/day for three months) or placebo, in addition to standard multidrug treatment. They found that prednisolone can prevent reaction and impairment of nerve function at four months, but only in people without pre-existing nerve damage, and the effect was not sustained at one year. Routine use of prophylactic steroids in all patients with multibacillary leprosy is not justified, say Lockwood and Kumar (p 1447) in an accompanying editorial.
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Pancreatitis is more common, but results are not improving
Pancreatitis has become more common in the past 35 years, but survival has not improved since the 1970s. Goldacre and Roberts (p 1466) found that admissions for acute pancreatitis in southern England increased between 1963 and 1998, from 4.9 to 9.8 per 100 000 people, particularly among the younger age groups. Mortality was 14.2% in 1963-74, 7.6% in 1975-86, and 6.7% in 1987-98. Death rates in the first month after an attack are about 30 times higher than death rates in the general population.
Cancer trials satisfy the uncertainty principle
Enrolling patients into trials is ethical when there is uncertainty about which treatment is more appropriate for them—the "uncertainty principle." Reviewing 93 cancer trials and 103 randomisations from the United States, Joffe and colleagues (p 1463) found that, on average, the experimental treatment resulted in slightly better disease control than standard treatment did. The heterogeneity of results and the small average effect indicate that on average these trials followed the uncertainty principle.
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Lung cancer patients feel stigmatised
Educational interventions help people quit smoking, but they often portray a dreadful death, which may exacerbate fear and anxiety, and they increase the stigma experienced by patients with lung cancer. Chapple and colleagues (p 1470) found that patients felt particularly stigmatised because the disease is strongly associated with smoking. Many felt unjustly blamed for their illness, and those who resisted victim blaming emphasised the culpability of tobacco companies. Stigmatisation can deter patients from seeking support and can have negative financial consequences for patients.
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Nursing home effect may explain high mortality
Looking after patients who live in nursing homes, and who are more likely to die than patients in the community, may explain excessively high mortality in general practice. Mohammed and colleagues (p 1474) analysed the case mix and results of two general practitioners flagged up by the Shipman inquiry as having higher mortality than expected, and they found that the GPs were looking after a high proportion of patients living in nursing homes, which explained their results. GPs with high mortality merit a proper investigation for credible causes, say the authors.
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Clinical databases are common, but need improving
Multicentre clinical databases exist in all areas of health care, but they are unevenly distributed and of differing quality. Reviewing 105 databases across the United Kingdom, Black and colleagues (p 1478) found that cancer and surgery were better covered than other specialties, and databases varied greatly in size, scope, geographical areas covered, and quality. Audit and research potential is not fully used, say the authors; considerable scope for improvements exists, which could be facilitated by a national support unit.
Treat minor burns effectively
Most minor burns can be safely managed in primary care. In the third article of our ABC of burns (p 1487), Hudspith and Rayatt give some important tips on how to treat patients with minor burns. The first aid given can influence the final cosmetic outcome: stopping the burning process, prompt cooling with tepid tap water, covering the burn (cling film is ideal), and keeping the patient warm is paramount. Burns should be kept clean, but routine use of antibiotics should be discouraged, say the authors. If the burns have not healed within two weeks, refer the patients to a burn surgeon.
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