March 25
American children now
receive up to 44 vaccine injections by the time they are 18 years old.
Jonathan Temte, a US family physician who is a liaison to the CDC�s Advisory
Committee on Immunization Practices,
discusses how vaccines are
evaluated and recommended, using the new hepatitis A vaccine as an example.
Whereas early vaccines were for diseases that were both common and serious,
newer vaccines tend to be for diseases that are either common (chickenpox)
or lethal (meningococcal disease) but not both. That said, most vaccines are
in the rare category of interventions that are not only cost effective but
also cost saving.
Most experts agree that
mammography can save lives by detecting breast cancer in its early,
treatable stages, but how do we evaluate newer screening tests for breast
cancer? Les Irwig and colleagues
discuss this, illustrating the need to balance increased sensitivity
(which is good) with increased overdetection (which is bad). An important
question is whether new breast cancer screening tests, such as magnetic
resonance imaging, need to be evaluated with long, expensive, randomized
controlled trials. The answer is probably not. Whether a shorter RCT is
required or an even shorter paired cross sectional study will suffice
depends on how similar the new and the old tests are.
Chronic low back pain is
an important and common problem in primary care, often frustrating patients
as well as doctors. Lisa Hsieh et al
compared the effectiveness of
acupressure and physical therapy for LBP in a randomized controlled trial
conducted in Taiwan. They found that patients randomized to acupressure
therapy had significantly better clinical outcomes, both immediately after
treatment and six months later, than those who received physical therapy.
The results are encouraging. In an accompanying
editorial, however, Helen Frost
and Sarah Stewart-Brown urge caution, pointing out that the interventions
were not well described, patients could (of course) tell which treatment
they received, and there is no evidence that the intervention can be
exported to other doctors. More research is needed.
March 18
The obesity epidemic
seems to affect everything. Anesthesiology resident Andrew Nisbet
measured pelvic CT scans from
100 consecutive patients to determine whether standard gluteal intramuscular
injections would indeed reach muscle in them. He found that between 12 and
72 of the patients�depending on needle selection and injection path�had too much
subcutaneous fat for an IM shot. Conclusion: probably best to deliver IM
injections to our increasingly heavy population via the deltoid muscle,
especially in overweight patients.
David Hunter and David
Felson review the diagnosis and
treatment of the most common cause of mobility restriction in the
elderly�osteoarthritis. They emphasize that the diagnosis is mainly a
clinical one and warn against ordering too many blood tests. False-positive
results, which are common in the elderly, lead to much unnecessary further
testing. Treatment should begin with education and non-pharmacologic
interventions, including weight loss, exercise, physical therapy, and, when
appropriate, knee braces.
Are population
approaches to prevention better than those delivered in the clinical
setting? Epidemiologist Geoffrey Rose calculated 20 years ago that moving
population norms of blood pressure or cholesterol a little would do a lot
more than treating patients with a single risk factor, like an elevated
cholesterol level. Douglas Manuel and colleagues
argue that today�s
multifactoral risk scores better identify patients who will benefit from
therapy. Intervening in these patients will save more lives than either
treating people with high cholesterols or trying to lower cholesterol in the
entire population. It�s an important point.
Finally, journalist
Janice Tanne reviews a
suspenseful new American reality television program, Miracle Workers,
about patients who receive life-changing or life-saving surgery. She wants
to know who gets on the show, who is paying for this surgery, and if the
surgery is so necessary why our health care system doesn�t pay for it.
March 11
Do hip protectors prevent hip fractures? Generally they have been thought to
help most in institutionalized elderly patients. Now Martyn Parker and
colleagues present a systematic review that concludes hip protectors
are ineffective in the home and of uncertain effectiveness in institutions.
In an accompanying editorial, Sophia de Rooij discusses some
technical issues in this research and suggests that the widespread use of
hip protectors not be advocated. More research needs to be done in nursing
homes and other high-risk settings.
Inquiring about patient preferences is all the rage. This is especially
appropriate in patients receiving palliative care. S Noble et al
interviewed 28 patients with metastatic cancer about their preferences for
prophylactic anticoagulation. They found that the patients universally
preferred injections of low molecular weight heparin to wearing antiembolic
stockings. The heparin allowed them a better quality of life (compared to
wearing the stockings) and gave them a feeling of safety and reassurance.
Sara Brown and Nick Reynolds review a common and frustrating skin
problem�eczema�emphasizing that it causes a considerable financial and
psychological burden on families who have a child with this chronic
condition. Topical steroids and emollients remain the first line therapies,
but newer treatments, both topical and systemic, are available for more
severe cases.
In the US, it seems that every second TV commercial is for erectile
dysfunction products. Jonathan Rees and Biral Patel present a brief
approach for the primary care doctor to follow in caring for patients with
this common problem. They emphasize that, despite the advertising, most
patients are reluctant to discuss ED. Also, make sure to investigate
possible causes of the ED (coronary artery disease, diabetes, peripheral
vascular disease) even while treating it.
March 4
The US Preventive Services Task Force recommends screening and behavioral
counseling for alcohol misuse in primary care settings. One of the screening
tools they endorse is the alcohol use disorders identification test, a 10
question instrument that was
evaluated by Simon Coulton and colleagues in men attending GP clinics in
Wales. They concluded that the AUDIT is more sensitive and specific than
various blood tests often used to detect alcoholism, and more cost effective
as well.
Is wine a healthier drink than beer, or is it that wine drinkers eat
healthier foods? Ditte Johansen and other Danish researchers shed some light on this
question with a large, cross sectional
study of 3.5 million transactions at
Danish supermarkets. They found that wine drinkers purchased significantly
more �Mediterranean� diet foods�olives, vegetables, fruit, and poultry�while
beer drinkers purchased more unhealthy foods such as chips, cold cuts,
sugar, and prepared items.
T J Murray reviews the
diagnosis and treatment of multiple sclerosis, pointing out that magnetic
resonance imaging has revolutionized the diagnosis of MS, although it is not
helpful in following progression of the disease. While better treatments are
on the horizon, short term intravenous corticosteroids are still the
treatment of choice for exacerbations.
Finally, a brief obituary by
Caroline Richmond recounts the path breaking career of heart surgeon Norman
Shumway.