This week in the BMJ
Volume 329, Number 7470, Issue of 9 Oct 2004Ultrasonography is not the only way to diagnose DVT
Ultrasonography is not the only way to diagnose DVT
Patients with abnormal results on d-dimer testing and a low clinical probability of deep venous thrombosis (DVT) do not need ultrasonography to exclude the diagnosis. Reviewing 12 studies including 5431 patients, Fancher and colleagues (p 821) found that normal results from a less sensitive d-dimer test would exclude the likelihood of DVT in 99.5% of patients with a low clinical probability of DVT, and a normal highly sensitive d-dimer test would exclude the diagnosis among all patients at low or moderate risk. These patients would not require additional tests, say the authors.
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Use ACE inhibitors in patients with diabetic nephropathy
Angiotensin converting enzyme (ACE) inhibitors may be the best choice for patients with diabetic nephropathy. Reviewing 43 trials, Strippoli and colleagues (p 828) found that ACE inhibitors, but not angiotensin II receptor antagonists, improved survival of these patients. The drugs had a similar effect on renal function. Because of the lack of good quality trials, the relative effects of ACE inhibitors and angiotensin II receptor blockers on survival is not known.
Paediatric cardiac surgeons are getting better
Mortality for paediatric cardiac surgery in the United Kingdom has declined over the past decade. Analysing more than 6500 paediatric operations, Aylin and colleagues (p 825) found that mortality for all centres fell from 12% in 1991-5 to 4% in 1999-2002. At Bristol, mortality for open heart operations in children aged under 1 year fell from 29% to 3%, below the national average; Oxford continues to have a higher mortality than average, not affected by adjustment for procedure.
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School runs do not affect physical activity
Being driven to school does not affect the overall physical activity of 5 year olds. Analysing the activity of 150 children who were in the first year of primary school, Metcalf and colleagues (p 832) found that twice as many walked to school (median journey 0.7 km; median journey time six minutes) as were taken by car. Activity during walking to school accounted for only 2% of total weekly activity, and total activity was the same in both groups of children.
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Radiological risks are not explained well
Informed consent for radiological examinations is often not sought, and even when it is, patients are often not fully informed, even for considerable levels of radiation exposure and long term risk. Picano (p 849) argues that risk might easily be communicated for each examination by reporting the dose in multiples of the dose from a chest x ray and the risk of cancer as number of extra cases in the exposed population. Patients should be told about the radiation dose of the higher risk examinations.
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Early contact with patients is beneficial
Medical students and teachers favour having clinical experience early in medical school. Interviewing 64 students, staff, and curriculum leaders from three university medical schools in the United Kingdom, Dornan and Bundy (p 834) found that early experience can generate greater motivation and confidence, greater social and self awareness, and better theoretical understanding among students. A lack of early experience can demotivate students and leave them vulnerable to negative emotions when they finally enter the clinical environment.
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