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US
editor�s choice
August 26
Furosemide
(called frusemide in the UK) is commonly given to patients with new or
impending renal failure to induce diuresis. Kwok Ho and David Sheridan
performed a
meta-analysis of nine trials of this treatment to assess whether it
actually helps prevent or treat renal failure. They found no significant
effect of furosemide on mortality, dialysis time, or any other measures. In
an accompanying
editorial, David Bennett-Jones points out that while many physicians
feel that furosemide treatment helps prevent oliguric renal failure, the
priorities in treating acute renal failure should be to �optimize fluid
balance, treat underlying causes, and initiate renal replacement therapy at
the appropriate time.�
Obsessive-compulsive disorders are among the most disabling conditions and
can present at any age to any type of doctor. In a
clinical review of this problem, I Heyman et al emphasize the utility of
a six-question screen for patients who seem to have inappropriate fears or
compulsive behaviors or thoughts. Treatments, including cognitive behavior
therapy and drugs, can help this chronic remitting condition.
Sandra
Dunkelberg, a German general practitioner,
writes movingly about her experience with her newborn daughter�s
mysterious failure to grow. The lessons from this piece are many: diagnosis
is not everything (she remains undiagnosed at three years of age); sometimes
further diagnostic testing seems to be only in the interest of specialists;
treatments without good evidence may be useful; and with chronic illness it
is important to focus on the positives rather than just on pathology and
abnormalities.
Finally, a
US county health officer, Joshua Lipsman,
recounts his struggles to finance and deliver currently needed public
health services in a time of hysteria about potential future threats. His
job is to balance the �tension�between what we see and what we only imagine
but fear deeply.�
August 19
This week�s
BMJ has a number of articles from and about China. They include a
study documenting the effects of, and an
editorial
on, China�s �one child� policy; a
discussion of lessons learned in China from the SARS epidemic and
their implications for avian influenza; and a fascinating
essay on the difficulties of trying to scientifically evaluate traditional
Chinese medical treatments.
More
conventionally, Catherine Smith and J Barker
review the cause,
diagnosis, effects, and management of psoriasis. They emphasize that the
mainstay of treatment remains topical therapies and that most patients can
be managed in primary care settings. More severe cases demand more
sophisticated treatments, including systemic drugs such as methotrexate and
the newer biological parenteral agents.
The perils
of relying on serum vitamin B-12 assays in diagnosing B-12 deficiency are
illustrated by a
lesson of the week from Vinod Devalia. Two patients
are discussed, one with repeated �false normal� serum levels despite anemia
and B-12 deficiency that responded to treatment, and a second with very low
levels who did not have B-12 deficiency. The author emphasizes that the B-12
assay has always been problematic and is not definitive. Best to treat when
in doubt, as the risks of non-treatment (or misdiagnosis) are usually
greater than those of a course of B-12 injections.
August 12
A recurrent
question in primary care is whether to treat uncomplicated (and seemingly
benign) conjunctivitis with antibiotics. Hazel Everitt and colleagues
performed a
randomized controlled trial of three strategies for treating bacterial
conjunctivitis: immediate antibiotics, delayed antibiotics in two to three
days at the patient�s or parent�s discretion, or no antibiotics. They found
that the best strategy seemed to be delayed antibiotics, combining good
clinical outcomes with less overtreatment and fewer visits to the doctor. In
an accompanying
editorial, Remco Rietveld et al comment that, although multiple
meta-analyses have shown that antibiotics for many minor illnesses (ear
infections, upper respiratory infections, conjunctivitis) may shorten
bacterial illnesses and prevent complications, the number of patients needed
to be treated in order to improve the clinical outcome for just one is
usually quite large. They urge caution in antibiotic treatment and recommend
the delayed prescribing alternative.
Postoperative nausea and vomiting lengthen hospital stays and occasionally
lead to major complications. To tackle this problem, Jan Wallenborn and
others
randomized over 3000 patients to receive intraoperative dexamethasone
alone or in combination with three different dosages of metoclopramide. They
found that as the metoclopramide dose increased, the rate of nausea and
vomiting decreased. Brian Sweeney comments in an
editorial that using dexamethasone and metoclopramide would save money
compared with the newer, more expensive anti-nausea drugs. He recommends
that the old and new drugs for this problem be compared in a proper
randomized trial.
Finally,
Rhys Beynon and colleagues
review the diagnosis and treatment of infective endocarditis. Fever and
a heart murmur are still the two most common presenting findings in patients
with an increased risk for the disease: intravenous drug users and those
with a history of heart valve disease or surgery. Blood cultures usually
make the diagnosis. When they are negative in high risk patients, sonography
and serologic tests may be helpful. Treatment for most patients is six weeks
of the appropriate intravenous antibiotics.
August 5
The general
advice for treatment of purulent rhinitis is not to use antibiotics. In a
systematic review and meta-analysis of randomized controlled trials of
antibiotic treatment, however, Bruce Arroll and Tim Kenealy find that
antibiotics probably are somewhat effective, helping perhaps one out of
seven patients treated. The harms associated with antibiotics use are
generally small. Because of the small likelihood of improved outcomes, they
don�t recommend routine antibiotic treatment, reserving it for patients with
long-standing or very symptomatic cases.
Bruce
Campbell
reviews the management of a common problem, varicose veins. He
recommends that patients be reassured that the long term risk of varicose
veins is minimal and that they are mainly a cosmetic problem. Support hose
may provide symptomatic relief for the aching that can be associated with
this problem, and surgery provides a safe and effective cure for severe
cases.
Finally, in
a
lesson of the week, Kalyan Kumar Gangopadhyay and colleagues present the
case of a patient with a history of radioiodine therapy for hyperthyroidism
who set off an airport screening alarm. In an accompanying
editorial, Daniel Cuthbertson and John Davidson advise all such patients
to carry their radiation certificates with them while traveling. The time
needed for the radiation to subside to undetectable levels varies with the
dose, individual metabolism, and the sensitivity of the airport radiation
detectors.
Archive of US Highlights
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August 26
Early intervention in acute renal failure
David N
Bennett-Jones
Meta-analysis of frusemide to prevent or
treat acute renal failure
Kwok M
Ho, David J Sheridan
Obsessive-compulsive disorder
I Heyman,
D Mataix-Cols, N A Fineberg
A patient�s journey: our special girl
Sandra
Dunkelberg
Between Chicken Little and the four
horsemen of the apocalypse
Joshua
Lipsman
August 19
China�s one child policy
Malcolm
Potts
Family
size, fertility preferences, and sex ratio in China in the era of the one
child family policy: results from national family planning and
reproductive health survey
Qu Jian
Ding, Therese Hesketh
Psoriasis and its management
Catherine H Smith, J N W N Barker
Diagnosing vitamin B-12 deficiency on the basis of serum B-12 assay
Vinod
Devalia
What we
have learnt from SARS epidemics in China
Nanshan
Zhong, Guangqiao Zeng
Research
priorities in traditional Chinese medicine
Jin-Ling
Tang
August 12
Antibiotics for upper respiratory tract
infections and conjunctivitis in primary care
Remco P Rietveld et al
Postoperative nausea and vomiting
Brian
Sweeney
A randomised controlled trial of management
strategies for acute infective conjunctivitis in general practice
Hazel A
Everitt et al
Prevention of postoperative nausea and
vomiting by metoclopramide combined with dexamethasone: randomised double
blind multicentre trial
Jan
Wallenborn et al
Infective endocarditis
Rhys P
Beynon et al
August 5
What to tell patients about radioiodine
therapy
Daniel J Cuthbertson, John
Davidson
Are antibiotics effective for acute
purulent rhinitis? Systematic review and meta-analysis of placebo
controlled randomised trials
B Arroll, T Kenealy
Varicose veins and their management
Bruce Campbell
Triggering radiation alarms after
radioiodine treatment
Kalyan
Kumar Gangopadhyay, Francis Sundram, Parijat De
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