This week in the BMJ
Volume 331, Number 7530, Issue of 17 Dec 2005Dose of vitamin A could be halved
Dose of vitamin A could be halved
The dose of vitamin A that the World Health Organization currently recommends as routine food supplementation for children in low income countries could safely be halved. Stabell Benn and colleagues (p 1428) randomised nearly 5000 children aged 6 months to 5 years to the recommended dose or half of it. After nine months, mortality in children who received a lower dose was lower than in those who received the whole dose, as was hospital case fatality in girls (but not boys). However, in children aged 6-18 months the lower dose was associated with slightly higher morbidity.
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Placental malaria strikes smaller women more severely
Shortness (stunting) and skeletal smallness and thinness (wasting) of pregnant women are associated with increased risk and increased severity of placental malaria. A cohort study in Congo in 1996-8 by Lovel and colleagues (p 1439) included more than 400 consecutive Bantu women with a singleton pregnancy. The trend in severity suggests the existence of a causative biological mechanism. The authors question whether triaging prophylaxis to short and thin pregnant women would be better than the current treatment only protocol.
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GPs with special interests are good but costly
General practitioners with a special interest in dermatology provide a more accessible service than hospital outpatient clinics, while achieving similar clinical outcomes—and are preferred by patients. Salisbury and colleagues (p 1441) randomised nearly 800 patients who were referred to a hospital dermatology clinic with non-urgent conditions to being seen by a general practitioner with a special interest in dermatology or usual hospital outpatient care. In an economic evaluation, Coast and colleagues (p 1444) found that GPs with a special interest were as good as or better than hospital care, but also more costly.
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Fewer drugs are being prescribed to children with depression
In Ireland, prescriptions of antidepressants to children under 16 years old with depression showed a significant downward trend between 2001 and 2004, but prescribing of selective serotonin reuptake inhibitors has not reduced despite safety warnings. Bennett and colleagues (p 1451) used the General Medical Services claims database to evaluate the pattern of prescribing antidepressants to children and compared it with prescribing to adults. In 2003, 43 per 1000 children were prescribed an antidepressant, and 60% of them received only one prescription. The pattern and trends don't reflect those of prescribing antidepressants to adults.
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When markets reform health care
Using market mechanisms to shape the healthcare system has some advantages over top-down management, but there are also costs, unintended and perverse consequences, and potential for damaging some of the most admirable qualities of the system, argues Edwards on p 1464. The English healthcare market will be different from conventional markets, so it is difficult to predict how the healthcare system will behave when it is market driven. Rather than leading to an increase in quality, competition and market incentives could lead to the fragmentation of care, which could greatly affect patients with chronic diseases, who need continuity and integration of care.
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