This week in the BMJ

Volume 333, Number 7571, Issue of 7 Oct 2006

[Down]Serological tests for kala-azar work well
[Down]Combined antithrombotic therapy is risky
[Down]Joint crisis plans seem cost effective in psychosis
[Down]Living organ donors should be paid
[Down]Trust depends on more than competence

Serological tests for kala-azar work well

The direct agglutination test and rK39 dipstick have a similar, good to excellent performance for the diagnosis of visceral leishmaniasis (kala-azar). Chappuis and colleagues (p 723) carried out a meta-analysis of 43 original studies evaluating the two diagnostic tests and found similar sensitivity estimates of 94.8% for the direct agglutination test and 93.9% for the rK39 dipstick. However, sensitivities were lower for patients from east Africa. Specificity estimates varied widely and were influenced by type of controls. The authors conclude that both tests generally work well and should be more widely used, but their lower performance in some situations show that better diagnostic tools need to be developed.


Figure 1
Credit: ANDY CRUMP/TDR



[To top]

Combined antithrombotic therapy is risky

Combined antithrombotic drug treatment is associated with high incidence of serious upper gastrointestinal bleeding. Hallas and colleagues (p 726) matched 1443 cases of serious upper gastrointestinal bleeding with over 55 000 controls and looked at their exposure to antithrombotic agents alone or in combination. Adjusted odds ratios associating drug use with gastrointestinal bleeding were between 1 and 2 for low dose aspirin, clopidogrel, dipyridamole, and vitamin K antagonists alone. Corresponding figures for aspirin in combination with clopidogrel, vitamin K antagonists, or dipyridamole were 7.4, 5.3, and 2.3.


Figure 1
Credit: TEK/SPL



[To top]

Joint crisis plans seem cost effective in psychosis

Joint crisis plans, a form of advance agreement for people with severe mental illness, may be more cost effective than standardised service information. Flood and colleagues (p 729) randomised 160 people with psychotic illness or non-psychotic bipolar disorder to a joint crisis plan or standardised service information (plus usual care) and found that crisis plans were associated with less service use and lower costs on average. The differences were not significant, but cost effectiveness acceptability curves suggested a greater than 78% probability that joint crisis plans are more cost effective.


Figure 1
Credit: WILL & DENO MCINTYRE/SPL



[To top]

Living organ donors should be paid

Controlled, regulated compensation to living organ donors should be permitted as with donation of other body material, says Amy Friedman (p 746). In the light of severe organ shortages, desperation among people awaiting transplantation, and black markets for kidneys purchased from living donors, she questions why everyone but the donor derives tangible benefit from a living donor transplant. She then discusses how regulation and payment should work in a legalised system to guarantee equitable access.


Figure 1
Credit: VICTOR DE SCHWANBERG/SPL



[To top]

Trust depends on more than competence

The decision of a supervisor to trust a trainee to manage a critically ill patient is based on much more than tests of competence, says Olle ten Cate (p 748). He argues that adequate performance includes the ability and inclination to apply competence in a way that optimises the outcome of professional activities. He discusses how these judgments can be incorporated into assessments and suggests that identifying entrustable professional activities may help competency based assessment and curriculums.


Figure 1
Credit: CHRISTINE KENNEDY/ALAMY



[To top]

Access jobs at BMJ Careers
Whats new online at Student BMJ