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

November 25

It�s Thanksgiving this week, which means feasting for many in the United States. In an (un)timely reminder of the association between lifestyle and disease, this week�s BMJ carries various articles on heart disease.

Predicting the risk of death or myocardial infarction in patients with acute coronary syndrome is challenging because of the diverse clinical presentations. To guide triage and key management decisions, however, risk assessment is essential. Fox and colleagues report a prospective multinational observational study of 43 810 patients in 94 hospitals in 14 countries in Europe, North and South America, Australia, and New Zealand. They developed a new and widely applicable tool, the global registry of acute coronary events (GRACE) scoring system, using nine readily identifiable variables that independently predict death or myocardial infarction. Junghans and Timmis in the accompanying editorial balance the advantages against the disadvantages and come out wondering whether this new scoring system is really so very different from other attempts at refining the process of risk assessment�or whether what�s really needed is a closer look at why risk assessment in general is so difficult to adopt in clinical practice.

More on matters of the heart: in the analysis and comment section, Wald and colleagues debate the evidence from various types of study on a possible association of raised homocysteine concentrations and cardiovascular disease and on whether folic acid, which lowers homocysteine, will help reduce the risk. They take the view that, although the evidence is not conclusive, it is sufficient to support a modest protective effect of folic acid, but encourage continuing review of this position in the light of new evidence.

Prostate cancer is common and potentially serious, especially as most men with the disease have no symptoms. Few established risk prevention strategies exist, and testing has a poor positive predictive value. How, then to tackle a disease that in 2002 alone was diagnosed in 32 000 men in the United Kingdom, with more than 10 000 deaths attributed to it? US authors Timothy Wilt and Ian Thompson in a comprehensive clinical review discuss the evidence on risk factors and prevention, detection, and treatment, to help family doctors answer patients� questions, capture ongoing research priorities, and clarify unanswered questions. All this in an interesting and readable article that may appeal to educated patients and doctors alike.

This week's US Highlights were compiled by Birte Twisselmann, assistant editor (web).

November 18

In a new analysis of the saline versus albumin fluid evaluation (SAFE) study, the investigators examined clinical outcomes of over 6000 Australian patients in intensive care who had been randomized to receive either saline or albumin for their fluid resuscitation. Whether their initial serum albumin levels were high or low, there was no difference in mortality, length of stay, or other outcome variables between the two groups. In an accompanying editorial, J L Vincent points out that the SAFE study was undertaken to establish not whether albumin was better than saline, but whether it was as safe, which it was. He argues that no one would use albumin for all patients needing fluids and advocates a trial comparing albumin and saline in ICU patients who are at increased risk of complications.

Can increased physical activity reduce weight in preschool children? John Reilly et al performed a randomized controlled trial in 36 Scottish preschools with 545 children. Half the schools received a physical activity intervention consisting of three 30 minute physical education classes, classroom posters, and home resource packs. The other half served as controls. At six and 12 months, there was no difference between the BMI scores in the two groups of children, although the intervention group children had better movement skills. Antronette Yancey writes in an editorial that this result is unsurprising given the �dose� of the intervention and the fact that it was probably applied inconsistently in real world settings. Correct implementation of programs, as well as increased comprehensiveness, are probably needed to show a change in children�s weights.

Finally, this week�s issue has an ethical debate about whether it can ever be ethical to withhold prenatal testing. The case in point involves a fetus at risk for the gene for Huntington�s disease, which is detectable in utero. The disease is universally fatal but does not appear until young adulthood. Some ethical guidelines call for providing prenatal diagnosis only if the parents are planning to abort a fetus that is found to be affected. Martin Delatycki argues that it is appropriate to withhold the test if the parents are not planning an abortion on the grounds of autonomy�otherwise they will be denying their future child the right to determine when and if he learns his diagnosis. Rony Duncan and Bennett Foddy disagree, citing several arguments: in the first trimester, the fetus is part of the mother�s body and she should not be denied knowledge about her own body; a couple can never "know" with 100% certainty whether or not they will abort a fetus; and no one should be placed in the untenable position of having to lie to obtain a medical diagnostic test. As genetic medicine becomes more widespread, dilemmas such as this will likely increase.

November 11

Should we be screening our service men and women for mental disorders and alcoholism before they go into combat? Roberto Rona et al performed a follow-up study of 1885 members of the British armed forces who had completed a battery of mental health tests before the current Gulf war. They found correlations between the first and second round survey results, but the first tests did not predict important outcomes such as post-traumatic stress disorder or alcoholism. In a related editorial US Veterans Affairs consultant Kenneth Hyams points out that recruitment and training standards have increased considerably in modern armed forces and that it is unlikely that pre-deployment testing will identify many soldiers who will later develop mental health problems.

There are multiple ways to manage knee pain; in the US and UK we generally focus on treatment by primary care or specialist doctors. Elaine Hay and colleagues compared the effectiveness of community physical therapy sessions, pharmacist consultation, and usual care in a randomized controlled trial of about 300 elderly British patients with knee pain. After three months, the patients in the physical therapy and pharmacist groups had significantly improved pain control, function, and satisfaction as well as decreased pain medicine use. These improvements were not sustained at six and 12 month follow-ups, however. Carmel Hughes and Chris Bleakley suggest that the fall-off in improvement could have been due lack of continuing adherence to treatment, which wasn�t well measured in the study. In an editorial they suggest that the respective interventions might have been effective for a longer period if they were increased in �dosage� or combined.

Observational studies have found a protective effect of statin drugs in patients who develop serious infections such as pneumonia. To test this finding Sumit Majumdar and associates studied a cohort of 3415 Canadians admitted to hospitals with pneumonia. After adjusting for the fact that statin users tend to be healthier, they found no significant effect of pre-existing or concurrent statin use on mortality or intensive care unit admission rates. Reimar Thomsen discusses this "healthy user" effect in an editorial and cautions that it is often a problem in large-scale observational studies that report unexpected positive results.

November 4

Tennis elbow, or lateral humeral epicondylitis, is an overuse syndrome seen commonly in primary care. Most agree that steroid injections help, but little standardized research has been done on the condition. Leanne Bisset et al performed a randomized controlled trial in 198 community residents with tennis elbow, comparing one or two steroid injections, eight weekly physical therapy sessions, and a wait and see approach (which included advice on rest, analgesics, and bracing). They found a short term benefit of steroid injections that reversed after the first six weeks. At one year, the two non-injection alternatives had better outcomes. In an accompanying editorial, Nynke Smidt and Danielle van der Windt point out that other trials have also reported poor long term results for steroid injections. This could be due to steroid induced weakening of tendons (less likely) or to overuse because of rapid recovery leading to reinjury. For most patients, a long term �wait and see� policy may be most appropriate.

Are breast-fed children smarter? Yes, say many studies, but Geoff Der and colleagues use three different types of analyses�a prospective study of a US national database, a comparison of siblings from the same database, and a meta-analysis�to establish that the reason breastfed babies have higher IQs is that their mothers are smarter. Sandra Jacobson and Joseph Jacobson comment in an editorial that controlling for maternal IQ is crucial. There are plenty of good reasons that women should breast feed their babies, but increasing their child�s intelligence apparently isn�t one of them.

Finally, for over 30 years, Swan-Ganz (pulmonary artery) catheterization has been part of the standard of care in the management of critically ill patients. In an editorial, Simon Finfer and Anthony Delaney briefly review the evidence that these expensive devices actually help patients. A recent UK health technology assessment has reported that five large randomized controlled trials all failed to show any clinical benefit of pulmonary artery catheters. An accompanying economic analysis concludes that if use of these catheters were discontinued, there would be a net mortality benefit at a rather modest cost. It seems now that proponents of using pulmonary artery catheters need to show that these devices� known risks are outweighed by their as yet unproven benefits.

Archive of US Highlights

November 25
Risk assessment after acute coronary syndrome
Cornelia Junghans, Adam D Timmins

Prediction of risk of death and myocardial infarction in the six months after presentation with acute coronary syndrome: prospective multinational observational study
Keith A A Fox et al

Clinically localised prostate cancer
Timothy J Wilt, Ian M Thompson

Folic acid, homocysteine, and cardiovascular disease: judging causality in the face of inconclusive trial evidence
David S Wald et al

November 18
Resuscitation using albumin in critically ill patients
J L Vincent

Tackling childhood obesity
Antronette Yancey

Physical activity to prevent obesity in young children: cluster randomised controlled trial
John J Reilly et al

Effect of baseline serum albumin concentration on outcome of resuscitation with albumin or saline in patients in intensive care units: analysis of data from the saline versus albumin fluid evaluation (SAFE) study
Saline versus Albumin Fluid Evaluation Study Investigators

Refusing to provide a prenatal test: can it ever be ethical?
Rony E Duncan et al

November 11
Mental health screening before troop deployment
Kenneth Craig Hyams

The lesser known effects of statins
Reimar W Thomsen

Treatment of knee pain in primary care
Carmel M Hughes, Chris M Bleakley

Mental health screening in armed forces before the Iraq war and prevention of subsequent psychological morbidity: follow-up study
Roberto J Rona et al

Effectiveness of community physiotherapy and enhanced pharmacy review for knee pain in people aged over 55 presenting to primary care: pragmatic randomised trial
Elaine M Hay et al

Statins and outcomes in patients admitted to hospital with community acquired pneumonia: population based prospective cohort study
Sumit R Majumdar et al

November 4
Tennis elbow in primary care
Nynke Smidt, Danielle AWM van der Windt

Breast feeding and intelligence in children
Sandra W Jacobson, Joseph L Jacobson

Pulmonary artery catheters
Simon Finfer, Anthony Delaney

Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial
Leanne Bisset et al

Effect of breast feeding on intelligence in children: prospective study, sibling pairs analysis, and meta-analysis
Geoff Der et al