This week in the BMJ
Volume 330, Number 7492, Issue of 19 Mar 2005BNP is reliable in predicting prognosis of heart failure
BNP is reliable in predicting prognosis of heart failure
B-type natriuretic peptide (BNP) is a strong prognostic indicator for patients with heart failure regardless of the stage of disease. In a systematic review, Doust and colleagues (p 625) analysed 19 studies of the prognostic value of BNP in patients in all stages of heart failure, all clinical settings, and all lengths of follow-up, and five studies assessing its prognostic value in asymptomatic patients. In patients with heart failure, each 100 pg/ml increase in BNP was associated with a 35% increase in the relative risk of death. In asymptomatic patients, BNP > 20 pg/ml was associated with a doubled risk of death.
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Sharing stories may improve diabetes education
A new method based on informal storytelling may be acceptable and beneficial in overcoming the gap that exists in diabetes education of people from minority ethnic groups who do not speak English. Greenhalgh and colleagues (p 628) report the results of the action research framework, drawing primarily from narrative methods, which they used to develop and refine the new intervention. Training bilingual health advocates who then led the diabetes support and education groups using a "sharing stories" format were popular with staff and service users, but now need to be formally tested in a randomised controlled trial.
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Living with myalgic encephalomyelitis
Myalgic encephalomyelitis represents a conundrum of uncertainty in its diagnosis, treatment, and prognosis—and the existence of the disease as a clinical category is still in debate, say Ong and colleagues (p 648). They report on one patient's experience of arriving at a diagnosis and living with this chronic debilitating illness and its pain and uncertainty. This has been a challenge for both the patient and her general practitioner, who frankly write about their feelings, thoughts, and knowledge.
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The NHS is waking to the challenge of chronic conditions
In its improvement plan launched in June 2004, the United Kingdom's national health service outlined the importance of supporting the increasing number of people with long term conditions and minimising the impact of these on their lives. On page 657, Wilson and colleagues discuss whether the NHS is rising to this challenge. They look at how system changes affect people with chronic conditions, and at what problems might arise if these changes are not properly applied or regulated.
Specialists should get more involved in the care of chronic patients
The interface between primary and specialist care requires more effective bridging in chronic illness, argues Gask on page 651. She says that consultant care is currently available to only a small proportion of people with chronic illness, but specialists' expertise is essential in ensuring that all patients get the best treatment. The changing role of consultants in long term treatment of patients with chronic diseases needs two key conceptual shifts: population based care and stepped care pathways.
Moving beyond guidelines in treatment of COPD
Guidelines for prognosis, diagnosis, and treatment of chronic obstructive pulmonary disease (COPD) have been published and are updated regularly, but the guidelines lag behind developments in clinical research, say Cooper and Tashkin (p 640). They review the recent developments in inhaled treatments and describe a practical, patient oriented approach to the hierarchical implementation of pharmacotherapy in COPD.
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Improving the doctor-patient relationship in chronic illness
Collaborative management of chronic illness is undermined by neglect of emotional and psychological factors in both the patient and the doctor, argue Campbell and McGauley (p 667). They highlight the gap between the importance of the rising number of chronic diseases and the relatively inadequate attention to the effect of managing chronic illness on the doctor and how this manifests in the therapeutic relationship. Drawing on their work in a high secure psychiatric hospital, they suggest how the gap can be addressed in medical education.
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