bmj.com -- US highlights

US Highlights

Here are items from recent BMJ issues that may be of particular interest to American readers. Happy reading. Comments welcome.

Douglas Kamerow
US editor

US editor�s choice

December 23-30

As usual, the Christmas double issue of the BMJ is seasonal, inspiring, humorous, entertaining, and bizarre. There is too much good stuff to describe it all, but here are some highlights.

Ever wonder how sword swallowers do it and how they escape injury? Brian Witcombe and Dan Meyer surveyed members of a sword swallowing society to find out. Turns out that relaxation and practice are the keys to successful sword swallowing, but injuries (usually minor) and "sword throat" are relatively common.

Donald Combs inspires with his predictions of future technologies that will transform medicine. From nanotechnology that allows miniaturized cameras and sensors inside the body to robotics that create customized replacement joints, everything he mentions is being developed now.

Mark Bailey and Janaka de Silva discuss a Sri Lankan classification of diseases and the sanni masks that represent various conditions. The color photos of the masks, representing dermatologic, gastrointestinal, and psychiatric maladies, are alternately frightening and humorous. The masks are used in exorcism rituals to treat diseases.

Architectural critic Edwin Heathcote describes a series of inspiring new oncology buildings designed by leading architects. In each of the Maggie�s Centres, as they are called, a healing spirit is built into the architecture. Though they are widely different in their design, each has been constructed to maximize access to nature and a feeling of scale, peace, and serenity.

And finally, the seasonal and bizarre are combined in A I Finall et al�s case history and an editorial by Edzard Ernst about people who inject mistletoe extract subcutaneously to treat cancer. Happy Christmas indeed.

Watch for the new look of BMJ on the web and in paper in January.

December 16

Does vaccinating nursing home staff against influenza make a difference? To answer this question, Andrew Hayward and colleagues performed a randomized controlled trial in 44 nursing homes. For two flu seasons, the staff in half the homes were offered influenza vaccine and those in the other half were not. During the 2003-4 flu season there were significant reductions in mortality, influenza-like illnesses and hospitalizations, and doctor visits for influenza-like symptoms. In 2004-5, a season of low influenza incidence, there were no significant differences. The authors conclude that vaccinating nursing home staff is effective in preventing mortality, illness, and health care utilization due to influenza. In an accompanying editorial, Rachel Jordan and Jeremy Hawker calculate that vaccinating nursing home staff against influenza is cost-effective as well, and they urge aggressive vaccination campaigns among all who work in elderly care establishments.

Drug eluting coronary artery stents have been much in the news lately. In an editorial, A H Gershlick and G Richardson discuss their risks and benefits. Compared to bare metal stents, the drug eluting variety have a lower incidence of in-stent restenosis, but at a cost of longer lasting injury to coronary artery wall endothelium. As a result, a small excess number of patients with drug-eluting stents have early thrombosis and even death. While the authors feel the small extra risk of stent thrombosis with drug eluting stents is outweighed by the 60-70% decrease in restenosis compared to bare metal stents, they advocate obtaining informed consent about these issues from patients.

Finally, Kenneth Poole and Juliet Compston review the management of osteoporosis, which is caused by decreased bone mass and disruption of bone micro-architecture, and is an important risk factor for vertebral and hip fractures. Falls are another important risk factor. Conditioning and environmental programs have been shown to prevent falls but not fractures. The keystones of osteoporosis treatment are dietary calcium, weight bearing exercise, smoking cessation, and pharmacotherapy with one of several effective classes of drugs.

December 9

Many patients with mildly to moderately severe community-acquired pneumonia are switched from intravenous to oral antibiotics early in their hospital stay to cut costs and get them out of hospital. Jan Oosterheert et al tested this strategy on patients with severe pneumonia in a randomized trial. They found that if the patients were clinically stable on hospital day three, switching them to oral antibiotics was safe and led to a two-day decrease in hospital length of stay. Graham Mills and Richard Laing state in an editorial that the days of 'one treatment fits all' for community acquired pneumonia are over and that more research should further define personally customized treatments for these patients.

The ever-growing population of aging baby-boomers makes finding treatments for Alzheimer�s dementia increasingly important. Maud Graff and colleagues conducted a randomized trial of 10 occupational therapy sessions in community dwelling Dutch patients with mild to moderate Alzheimer�s. The result was a clinically significant improvement in daily function, helping both the patients and their caregivers. In a related editorial, Jeannette Golden and Brian Lawlor point out that non-pharmacological treatments for Alzheimer�s such as these complement drug therapy and are very much needed.

Finally, R J Heine and colleagues review the management of hyperglycemia in type 2 diabetes. While they concede there is little clinical trial evidence for the algorithm they propose, they advocate institution of both lifestyle changes and metformin when the patient is first diagnosed with diabetes. Their advice is to stay ahead of hyperglycemia by adding a second oral agent or insulin before there is runaway hyperglycemia. Aggressively treating hyperglycemia offers the best chance of preventing complications and (possibly) slowing the decline of β-cell function.

December 2

Everyone uses Google, including doctors and patients. Should we rely on it to help make diagnoses? Hangwi Tang and Jennifer Ng evaluated Google�s diagnostic skills with 26 recent case studies from the New England Journal of Medicine. They found that in 15 of the cases they were able to find the ultimate diagnosis by Googling major search terms from the case record. While this doesn�t prove anything, and it certainly depends on the knowledge and skills of the Googlers, it does confirm that there is a lot of relevant information out there on the web. In a related editorial, Martin Gardner points out that all that Google is doing is searching"very quickly and widely" for medical terms and returning results that have a high number of matches, regardless of whether the term is a diagnosis, treatment, anatomic part, or anything else. Only with a future web that includes context and meaning - called the semantic web - will we have something approaching a true expert system.

Should doctors be prohibited from having sexual relations with their patients? Current guidelines in the US and UK prohibit such relationships with current patients, and the UK�s General Medical Council has just issued a warning - but not a prohibition - against sex with previous patients as well. Julian Sheather, in an editorial, feels that on balance the GMC is right. While there are certainly times when such a prohibition seems silly�when a doctor has treated a colleague in the emergency room, for example�or unnecessarily harsh�in rural areas or small towns�in general doctors should think long and hard before commencing a relationship with a former patient.

One big item on the agenda of the new Democratic Congress is decreasing the number of Americans without health insurance. Princeton economist Uwe Reinhardt asks if Democratic leadership is likely to result in meaningful change. He thinks not, because of low interest in raising taxes as well as a lack of consensus about how to go about it.

Finally, should we be giving statins to everyone with an increased heart disease risk? The Heart Protection Study Collaborative Group did a cost effectiveness modeling study of the lifetime use of 40 mg of simvastatin across a range of age and risk groups. They found that the medicine was cost effective for those with at least a 1% annual risk of a major vascular event�a much lower threshold than current prophylactic recommendations.

Archive of US Highlights

December 23-30
Mistletoe as a treatment for cancer
Edzard Ernst

Sword swallowing and its side effects
Brian Witcombe, Dan Meyer

Subcutaneous inflammation mimicking metastatic malignancy induced by injection of mistletoe extract
A I Finall et al

Maggie�s Centres
Edwin Heathcote

Startling technologies promise to transform medicine
C Donald Combs

Sri Lankan sanni masks: an ancient classification
Mark S Bailey, H Janaka de Silva

December 16
Influenza in elderly people in care homes
Rachel E Jordan, Jeremy I Hawker

Drug eluting stents
A H Gershlick, G Richardson

Effectiveness of an influenza vaccine programme for care home staff to prevent death, morbidity, and health service use among residents: cluster randomised controlled trial
Andrew C Hayward et al

Osteoporosis and its management
Kenneth E S Poole, Juliet E Compston

December 9
Severe community acquired pneumonia
Graham D Mills, Richard Laing