Showing papers in "BMJ in 1999"

Clinical guidelines: potential benefits, limitations, and harms of clinical guidelines.

Abstract: This is the first in a series of four articles on issues in the development and use of clinical guidelines Over the past decade, clinical guidelines have increasingly become a familiar part of clinical practice. Every day, clinical decisions at the bedside, rules of operation at hospitals and clinics, and health spending by governments and insurers are being influenced by guidelines. As defined by the Institute of Medicine, clinical guidelines are “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.”1 They may offer concise instructions on which diagnostic or screening tests to order, how to provide medical or surgical services, how long patients should stay in hospital, or other details of clinical practice The broad interest in clinical guidelines that is stretching across Europe, North America, Australia, New Zealand, and Africa (box) has its origin in issues that most healthcare systems face: rising healthcare costs, fueled by increased demand for care, more expensive technologies, and an ageing population; variations in service delivery among providers, hospitals, and geographical regions and the presumption that at least some of this variation stems from inappropriate care, either overuse or underuse of services; and the intrinsic desire of healthcare professionals to offer, and of patients to receive, the best care possible. Clinicians, policy makers, and payers see guidelines as a tool for making care more consistent and efficient and for closing the gap between what clinicians do and what scientific evidence supports. As guidelines diffuse into medicine, there are important lessons to learn from the firsthand experience of those who develop, evaluate, and use them.3 This article, the first of a four part series to reflect on these lessons, examines the potential benefits, limitations, and harms of clinical guidelines. Future articles will review lessons learned …

What is meant by intention to treat analysis? Survey of published randomised controlled trials

Abstract: Objectives: To assess the methodological quality of intention to treat analysis as reported in randomised controlled trials in four large medical journals. Design: Survey of all reports of randomised controlled trials published in 1997 in the BMJ, Lancet, JAMA , and New England Journal of Medicine . Main outcome measures: Methods of dealing with deviations from random allocation and missing data. Results: 119 (48%) of the reports mentioned intention to treat analysis. Of these, 12 excluded any patients who did not start the allocated intervention and three did not analyse all randomised subjects as allocated. Five reports explicitly stated that there were no deviations from random allocation. The remaining 99 reports seemed to analyse according to random allocation, but only 34 of these explicitly stated this. 89 (75%) trials had some missing data on the primary outcome variable. The methods used to deal with this were generally inadequate, potentially leading to a biased treatment effect. 29 (24%) trials had more than 10% of responses missing for the primary outcome, the methodsof handling the missing responses were similar in this subset. Conclusions: The intention to treat approach is often inadequately described and inadequately applied. Authors should explicitly describe the handling of deviations from randomised allocation and missing responses and discuss the potential effect of any missing response. Readers should critically assess the validity of reported intention to treat analyses. Key messages Intention to treat gives a pragmatic estimate of the benefit of a change in treatment policy rather than of potential benefit in patients who receive treatment exactly as planned Full application of intention to treat is possible only when complete outcome data are available for all randomised subjects About half of all published reports of randomised controlled trials stated that intention to treat was used, but handling of deviations from randomised allocation varied widely Many trials had some missing data on the primary outcome variable, and methods used to deal with this were generally inadequate, potentially leading to bias Intention to treat analyses are often inadequately described and inadequately applied

Dementia reconsidered: the person comes first

Abstract: Tom Kitwood Open University Press, £14.95, pp 176 ISBN 0335198554 ![][1] Rating: ![Graphic][2] The burden of dementia is borne not only by people with dementia, but by their carers, both informal and professional. The major direct financial costs are managed by the welfare sector, through the provision of community services and residential care, whereas indirect costs are largely attributed to informal carers. Advances in care practices would be of considerable benefit. The health sector has had its main impact in the area of dementia by providing skills and expertise necessary for comprehensive, holistic assessments. Kitwood challenges this medical model, which he labels as … [1]: /embed/graphic-1.gif [2]: /embed/inline-graphic-1.gif

Long term follow up

Abstract: In 1968,although an obstetrician by training, I was appointed as general surgeon to a mobile surgical team embarked in the aircraft carrier Eagle to provide cover for the naval task group covering the withdrawal from Aden. This eccentric appointment arose from a temporary shortage of available surgical specialists and was a cause of some amusement on board and some concern on my part. I was not reassured to hear that, in the second world war, the United States marine corps had recruited several obstetricians who were unwanted by the other services and found them to have the best battlefield mortality figures, since they were well used to working fast in a welter of blood. A further complication was …

Moderate alcohol intake and lower risk of coronary heart disease: meta-analysis of effects on lipids and haemostatic factors.

Abstract: Objective: To summarise quantitatively the association between moderate alcohol intake and biological markers of risk of coronary heart disease and to predict how these changes would lower the risk. Design: Meta-analysis of all experimental studies that assessed the effects of moderate alcohol intake on concentrations of high density lipoprotein cholesterol, apolipoprotein A I, fibrinogen, triglycerides, and other biological markers previously found to be associated with risk of coronary heart disease. Participants: Men and women free of previous chronic disease and who were not dependent on alcohol Studies were included in which biomarkers were assessed before and after participants consumed up to 100 g of alcohol a day. Interventions: Alcohol as ethanol, beer, wine, or spirits. Main outcome measures: Changes in concentrations of high density lipoprotein cholesterol, apolipoprotein A I, Lp(a) lipoprotein, triglycerides, tissue type plasminogen activator activity, tissue type plasminogen activator antigen, insulin, and glucose after consuming an experimental dose of alcohol for 1 to 9 weeks; a shorter period was accepted for studies of change in concentrations of fibrinogen, factor VII, von Willebrand factor, tissue type plasminogen activator activity, and tissue type plasminogen activator antigen. Results: 61 data records were abstracted from 42 eligible studies with information on change in biological markers of risk of coronary heart disease. An experimental dose of 30 g of ethanol a day increased concentrations of high density lipoprotein cholesterol by 3.99 mg/dl (95% confidence interval 3.25 to 4.73), apolipoprotein A I by 8.82 mg/dl (7.79 to 9.86), and triglyceride by 5.69 mg/dl (2.49 to 8.89). Several haemostatic factors related to a thrombolytic profile were modestly affected by alcohol On the basis of published associations between these biomarkers and risk of coronary heart disease 30 g of alcohol a day would cause an estimated reduction of 24.7% in risk of coronary heart disease. Conclusions: Alcohol intake is causally related to lower risk of coronary heart disease through changes in lipids and haemostatic factors. Key messages Results from observational studies provide strong evidence that moderate alcohol intake lowers risk of coronary heart disease Short term trials of alcohol intake show significant changes in concentrations of lipids and clotting factors The changes in concentrations of high density lipoprotein cholesterol, fibrinogen, and triglycerides associated with an intake of 30 g of alcohol a day should reduce risk of coronary disease by 24.7% Alcohol intake may be causally related to lower risk of coronary heart disease through changes in lipids and haemostatic factors

Evidence based cardiology: psychosocial factors in the aetiology and prognosis of coronary heart disease. Systematic review of prospective cohort studies.

Abstract: Do psychosocial factors cause coronary heart disease or affect survival among patients with coronary heart disease? Here we use an explicit methodological quality filter to review systematically the prospective cohort studies testing specific psychosocial hypotheses. This review of the epidemiological literature identifies the psychosocial factors that have been most rigorously tested. Only four psychosocial factors met the quality filter: type A/hostility, depression and anxiety, work characteristics, and social supports. The importance of other study designs—for example, ecological1 or nested case-control2–4 studies—is acknowledged. The review should be seen as complementary to existing reviews5–8 on single psychosocial factors and as a challenge to investigators in the field to ensure that the systematic review is made unbiased, kept up to date, and used to guide future hypothesis testing. #### Summary points In healthy populations, prospective cohort studies show a possible aetiological role for type A/hostility (6/14 studies), depression and anxiety (11/11 studies), psychosocial work characteristics (6/10 studies), social support (5/8 studies) In populations of patients with coronary heart disease, prospective studies show a prognostic role for depression and anxiety (6/6 studies), psychosocial work characteristics (1/2 studies), and social support (9/10 studies); none of five studies showed a prognostic role for type A/hostility Although this review can not discount the possibility of publication bias, prospective cohort studies provide strong evidence that psychosocial factors, particularly depression and social support, are independent aetiological and prognostic factors for coronary heart disease A psychosocial factor may be defined as a measurement that potentially relates psychological phenomena to the social environment and to pathophysiological changes. The validity and reliability (precision) of the questionnaire based instruments used to measure psychosocial factors has been improved through the use of psychometric techniques. By avoiding the unhelpful general term of “stress,” recent work has developed theoretical models—for example, the …

beta Blockade after myocardial infarction: systematic review and meta regression analysis.

Abstract: Objectives: To assess the effectiveness of β blockers in short term treatment for acute myocardial infarction and in longer term secondary prevention; to examine predictive factors that may influence outcome and therefore choice of drug; and to examine the clinical importance of the results in the light of current treatment. Design:Systematic review of randomised controlled trials. Setting: Randomised controlled trials. Subjects: Patients with acute or past myocardial infarction. Intervention: βBlockers compared with control. Main:outcome measures All cause mortality and non-fatal reinfarction. Results: Overall, 5477 of 54 234 patients (10.1%) randomised to β blockers or control died. We identified a 23% reduction in the odds of death in long term trials (95% confidence interval 15% to 31%), but only a 4% reduction in the odds of death in short term trials (−8% to 15%). Meta regression in long term trials did not identify a significant reduction in effectiveness in drugs with cardioselectivity but did identify a near significant trend towards decreased benefit in drugs with intrinsic sympathomimetic activity. Most evidence is available for propranolol, timolol, and metoprolol. In long term trials, the number needed to treat for 2 years to avoid a death is 42, which compares favourably with other treatments for patients with acute or past myocardial infarction. Conclusions: β Blockers are effective in long term secondary prevention after myocardial infarction, but they are underused in such cases and lead to avoidable mortality and morbidity.

The World Bank: Friend or foe to the poor?

Abstract: Education and debate p 865 Why should British and other western doctors be interested in the World Bank? This week's BMJ includes the first of Kamran Abbasi's articles on the World Bank (p 865),1 yet with health system reforms, performance reviews, racism in health, plummeting morale, and continued underfunding, haven't we got enough to occupy us? Yes, but what of the plight of the 1.3 billion people living in absolute poverty on less than $1 a day? Their health is as abysmal as their wealth, and until their poverty is relieved their health will not improve. The World Bank's mission statement is “to reduce poverty, and improve living standards by promoting sustainable growth and investment in people.”2 For health workers concerned with the pathology and relief of poverty, knowledge about the bank is as important as anatomy is to surgeons. Like the Christian churches in the nineteenth century, the bank has enormous influence in former colonies. It helps set, fund, and …

Catch-up growth in childhood and death from coronary heart disease: longitudinal study

Abstract: Objective: To examine whether catch-up growth during childhood modifies the increased risk of death from coronary heart disease that is associated with reduced intrauterine growth Design: Follow up study of men whose body size at birth was recorded and who had an average of 10 measurements taken of their height and weight through childhood Setting: Helsinki, Finland Subjects: 3641 men who were born in Helsinki University Central Hospital during 1924-33 and who went to school in Helsinki Main outcome measures: Hazard ratios for death from coronary heart disease Results: Death from coronary heart disease was associated with low birth weight and, more strongly, with a low ponderal index at birth Men who died from coronary heart disease had an above average body mass index at all ages from 7 to 15 years In a simultaneous regression the hazard ratio for death from the disease increased by 14% (95% confidence interval 8% to 19%; P Conclusion: The highest death rates from coronary heart disease occurred in boys who were thin at birth but whose weight caught up so that they had an average or above average body mass from the age of 7 years Death from coronary heart disease may be a consequence of poor prenatal nutrition followed by improved postnatal nutrition

Clinical guidelines: Developing guidelines

Abstract: This is the second in a series of four articles on issues in the development and use of clinical guidelines.

The SCOFF questionnaire : assessment of a new screening tool for eating disorders

Abstract: Eating disorders are among the most common psychiatric disorders in young women. Early detection and treatment improves prognosis, but presentation is often cryptic—for example, via physical symptoms in primary care. Ability to diagnose the condition varies and can be inadequate,1 and existing questionnaires for detection 2 3 are lengthy and may require specialist interpretation. No simple, memorable screening instruments are available for non-specialists. In alcohol misuse the CAGE questionnaire4 has proved popular with clinicians because of its simplicity. We developed and tested a similar tool for eating disorders— with questions designed to raise suspicion that an eating disorder might exist—before rigorous clinical assessment. We developed five questions addressing core features of anorexia nervosa and bulimia nervosa using focus groups of patients with eating disorders and specialists in eating disorders; we tested the questions in a feasibility study of patients and staff at an eating disorders unit None …

Population based study of social and productive activities as predictors of survival among elderly Americans

Abstract: Objectives: To examine any association between social, productive, and physical activity and 13 year survival in older people. Design: Prospective cohort study with annual mortality follow up. Activity and other measures were assessed by structured interviews at baseline in the participants9 homes Proportional hazards models were used to model survival from time of initial interview. Setting: City of New Haven, Connecticut, United States. Participants: 2761 men and women from a random population sample of 2812 people aged 65 and older. Main outcome measure: Mortality from all causes during 13 years of follow up. Results: All three types of activity were independently associated with survival after age, sex, race/ethnicity, marital status, income, body mass index, smoking, functional disability, and history of cancer, diabetes, stroke, and myocardial infarction were controlled for. Conclusions: Social and productive activities that involve little or no enhancement of fitness lower the risk of all cause mortality as much as fitness activities do. This suggests that in addition to increased cardiopulmonary fitness, activity may confer survival benefits through psychosocial pathways. Social and productive activities that require less physical exertion may complement exercise programmes and may constitute alternative interventions for frail elderly people. Key messages Little is known about predictors of survival among elderly people Physical activity is clearly good for health, but the potential benefits of social activities have not been studied Social and productive activities are as effective as fitness activities in lowering the risk of death Enhanced social activities may help to increase the quality and length of life

Breast feeding and obesity: cross sectional study

Abstract: Objective To assess the impact of breast feeding on the risk of obesity and risk of being overweight in children at the time of entry to school. Design Cross sectional survey Setting Bavaria, southern Germany. Methods Routine data were collected on the height and weight of 134 577 children participating in the obligatory health examination at the time of school entry in Bavaria. In a subsample of 13 345 children, early feeding, diet, and lifestyle factors were assessed using responses to a questionnaire completed by parents. Subjects 9357 children aged 5 and 6 who had German nationality.

Study of infectious intestinal disease in England: rates in the community, presenting to general practice, and reported to national surveillance

Abstract: Objective: To establish the incidence and aetiology of infectious intestinal disease in the community and presenting to general practitioners Comparison with incidence and aetiology of cases reaching national laboratory based surveillance Design: Population based community cohort incidence study, general practice based incidence studies, and case linkage to national laboratory surveillance Setting: 70 general practices throughout England Participants: 459 975 patients served by the practices Community surveillance of 9776 randomly selected patients Main outcome measures: Incidence of infectious intestinal disease in community and reported to general practice Results: 781 cases were identified in the community cohort, giving an incidence of 194/100 person years (95% confidence interval 181 to 208) 8770 cases presented to general practice (33/100 person years (294 to 375)) One case was reported to national surveillance for every 14 laboratory identifications, 62 stools sent for laboratory investigation, 23 cases presenting to general practice, and 136 community cases The ratio of cases in the community to cases reaching national surveillance was lower for bacterial pathogens (salmonella 32:1, campylobacter 76:1) than for viruses (rotavirus 35:1, small round structured viruses 1562:1) There were many cases for which no organism was identified Conclusions: Infectious intestinal disease occurs in 1 in 5 people each year, of whom 1 in 6 presents to a general practitioner The proportion of cases not recorded by national laboratory surveillance is large and varies widely by microorganismWays of supplementing the national laboratory surveillance system for infectious intestinal diseases should be considered

Decision aids for patients facing health treatment or screening decisions: systematic review

Abstract: Objective: To conduct a systematic review of randomised trials of patient decision aids in improving decision making and outcomes. Design: We included randomised trials of interventions providing structured, detailed, and specific information on treatment or screening options and outcomes to aid decision making. Two reviewers independently screened and extracted data on several evaluation criteria. Results were pooled by using weighted mean differences and relative risks. Results: 17 studies met the inclusion criteria. Compared with the controls, decision aids produced higher knowledge scores (weighted mean difference=19/100, 95% confidence interval 14 to 25); lower decisional conflict scores (weighted mean difference=−0.3/5, −0.4 to −0.1); more active patient participation in decision making (relative risk = 2.27, 95% confidence interval 1.3 to 4); and no differences in anxiety, satisfaction with decisions (weighted mean difference=0.6/100, −3 to 4), or satisfaction with the decision making process (2/100,−3 to 7). Decision aids had a variable effect on decisions. When complex decision aids were compared with simpler versions, they were better at reducing decisional conflict, improved knowledge marginally, but did not affect satisfaction. Conclusions: Decision aids improve knowledge, reduce decisional conflict, and stimulate patients to be more active in decision making without increasing their anxiety. Decision aids have little effect on satisfaction and a variable effect on decisions. The effects on outcomes of decisions (persistence with choice, quality of life) remain uncertain.

Efficacy and safety of rivastigmine in patients with Alzheimer's disease: international randomised controlled trial.

Abstract: Objectives: To assess the effects of rivastigmine on the core domains of Alzheimer9s disease. Design: Prospective, randomised, multicentre, double blind, placebo controlled, parallel group trial. Patients received either placebo, 1-4 mg/day (lower dose) rivastigmine, or 6-12 mg/day (higher dose) rivastigmine. Doses were increased in one of two fixed dose ranges (1-4 mg/day or 6-12 mg/day) over the first 12 weeks with a subsequent assessment period of 14 weeks. Setting: 45 centres in Europe and North America. Participants: 725 patients with mild to moderately severe probable Alzheimer9s disease diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders , fourth edition, and the criteria of the National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer9s Disease and Related Disorders Association. Outcome measures: Cognitive subscale of the Alzheimer9s disease assessment scale, rating on the clinician interview based impression of change incorporating caregiver information scale, and the progressive deterioration scale. Results: At the end of the study cognitive function had deteriorated among those in the placebo group. Scores on the Alzheimer9s disease assessment scale improved in patients in the higher dose group when compared with patients taking placebo (P v 16% (39/238)). Global function as rated by the clinician interview scale had significantly improved among those in the higher dose group compared with those taking placebo (P v 20% (46/230)). Mean scores on the progressive deterioration scale improved from baseline in patients in the higher dose group but fell in the placebo group. Adverse events were predominantly gastrointestinal, of mild to moderate severity, transient, and occurred mainly during escalation of the dose. 23% (55/242) of those in the higher dose group, 7% (18/242) of those in the lower dose group, and 7% (16/239) of those in the placebo group discontinued treatment because of adverse events. Conclusions: Rivastigmine is well tolerated and effective. It improves cognition, participation in activities of daily living, and global evaluation ratings in patients with mild to moderately severe Alzheimer9s disease. This is the first treatment to show compelling evidence of efficacy in a predominantly European population. Key messages In a 6 month trial rivastigmine was effective in treating the core cognitive and functional symptoms of patients with mild to moderate Alzheimer9s disease Rivastigmine at doses of 6-12 mg/day produces clinically relevant and statistically significant improvements in cognitive and global assessments, and in activities of daily living The effects of rivastigmine are dose dependent Rivastigmine was well tolerated in this population of elderly patients

Bullying, depression, and suicidal ideation in Finnish adolescents: school survey

Abstract: Objective: To assess the relation between being bullied or being a bully at school, depression, and severe suicidal ideation. Design: A school based survey of health, health behaviour, and behaviour in school which included questions about bullying and the Beck depression inventory, which includes items asking about suicidal ideation. Setting: Secondary schools in two regions of Finland. Participants: 16410 adolescents aged 14-16. Results: There was an increased prevalence of depression and severe suicidal ideation among both those who were bullied and those who were bullies. Depression was equally likely to occur among those who were bullied and those who were bullies. It was most common among those students who were both bullied by others and who were also bullies themselves. When symptoms of depression were controlled for, suicidal ideation occurred most often among adolescents who were bullies. Conclusion: Adolescents who are being bullied and those who are bullies are at an increased risk of depression and suicide. The need for psychiatric intervention should be considered not only for victims of bullying but also for bullies. Key messages About 1 in 10 schoolchildren report being bullied weekly at school Adolescents who are bullied or who are bullies have an increased risk of depression and suicidal ideation Bullies are often as depressed as those who are bullied, and suicidal ideation is even more common among bullies Interventions aimed at reducing bullying in schools, as well as psychiatric assessment and treatment of bullies and those who are bullied, might also prevent depression and suicidal ideation

Fetal origins of adult disease—the hypothesis revisited

Abstract: The idea that stimuli or insults during critical or sensitive periods in early life can have lifetime consequences is well established in developmental biology and has been termed “programming.”1 The first evidence for programming, obtained over 100 years ago, confirmed the critical period for imprinting in birds.2 Programming stimuli may be generated endogenously (for instance, internal hormonal signals3) or they may be environmental. One important type of environmental programming is that induced by early nutrition. Since McCance's studies in the 1960s on the long term effects of early nutrition in rats,4 numerous animal studies have shown that nutrition in infancy or fetal life can induce lifetime effects on metabolism, growth, and neurodevelopment and on major disease processes such as hypertension, diabetes, atherosclerosis, and obesity.5–8 If these phenomena applied in humans, it would be a matter of major public health and clinical importance. #### Summary points The hypothesis that adult disease has fetal origins is plausible, but much supportive evidence is flawed by incomplete and incorrect statistical interpretation When size in early life is related to later health outcomes only after adjustment for current size, it is probably the change in size between these points (postnatal centile crossing) rather than fetal biology that is implicated Even when birth size is directly related to later outcome, some studies fail to explore whether this is partly or wholly explained by postnatal rather that prenatal factors These considerations are critical to understanding the biology and timing of “programming,” the direction of future research, and future public health interventions The considerable research focused on early programming of adult outcomes in humans has taken two approaches: experimental, using early randomised nutritional interventions with prospective follow up (an approach that we have favoured9), and observational. Inferences from data based on observational approaches …

A template for defining a causal relation between acute intrapartum events and cerebral palsy: international consensus statement

Abstract: In 1997 the research committee of the Perinatal Society of Australia and New Zealand competitively funded a special initiative to bring together the modern literature on the causation of cerebral palsy, and to try to define an objective template of evidence to better identify cases of cerebral palsy where the neuropathology began or became established around labour and birth. Recently there have been many advances in a wide variety of scientific areas associated with cerebral palsy, and thus this multidisciplinary review may benefit research into the causation and prevention of cerebral palsy and may also help those who offer expert opinion when counselling in this area or giving such opinion in court. The corresponding task force was open to anyone who could make a scientific contribution to understanding in this area. The task force had representation from a wide range of clinical and scientific specialties. Submissions were sought from the society's 1000 members, which include scientists, pathologists, obstetricians, neonatalogists, midwives, neonatal nurses, and epidemiologists. International contributions were sought from those identified from the current literature as contributing to this area through peer reviewed research. They were not preselected for their views, and they were invited to join the corresponding task force Some international members joined later in the discussion process as word of this open debate reached them. During 1997 and 1998 multiple online electronic conferences were held, and in March 1998 many of the task force members were able to participate in a workshop in Alice Springs, Australia to discuss the fourth draft of the statement. Drafts of the statement were circulated and debated, with the sixth draft being discussed at an international telephone conference in October 1998. The paper continued to be redrafted eight times until consensus was reached. No opinion was excluded from the debate, but the …

Onset of adolescent eating disorders: population based cohort study over 3 years

Abstract: Objective: To study the predictors of new eating disorders in an adolescent cohort. Design: Cohort study over 3 years with six waves. Subjects: Students, initially aged 14-15 years, from 44 secondary schools in the state of Victoria, Australia. Outcome measures: Weight (kg), height (cm), dieting (adolescent dieting scale), psychiatric morbidity (revised clinical interview schedule), and eating disorder (branched eating disorders test). Eating disorder (partial syndrome) was defined when a subject met two criteria for either anorexia nervosa or bulimia nervosa according to the Diagnostic and Statistical Manual of Mental Disorders , fourth edition (DSM-IV). Results: At the start of the study, 3.3% (29/888) of female subjects and 0.3% (2/811) of male subjects had partial syndromes of eating disorders. The rate of development of new eating disorder per 1000 person years of observation was 21.8 in female subjects and 6.0 in male subjects. Female subjects who dieted at a severe level were 18 times more likely to develop an eating disorder than those who did not diet, and female subjects who dieted at a moderate level were five times more likely to develop an eating disorder than those who did not diet. Psychiatric morbidity predicted the onset of eating disorder independently of dieting status so that those subjects in the highest morbidity category had an almost sevenfold increased risk of developing an eating disorder. After adjustment for earlier dieting and psychiatric morbidity, body mass index, extent of exercise, and sex were not predictive of new eating disorders. Conclusions: Dieting is the most important predictor of new eating disorders. Differences in the incidence of eating disorders between sexes were largely accounted for by the high rates of earlier dieting and psychiatric morbidity in the female subjects. In adolescents, controlling weight by exercise rather than diet restriction seems to carry less risk of development of eating disorders. Key messages Adolescent females who diet at a severe level are 18 times more likely to develop an eating disorder than those who do not diet, and those who diet at a moderate level are five times more likely to develop an eating disorder High levels of psychiatric morbidity in females increase the risk of developing eating disorders by sevenfold Around two thirds of new cases of eating disorder arise in females who have dieted moderately The predominance of eating disorders in females is largely explained by the higher rates of earlier dieting and psychiatric morbidity Daily exercise seems to be a less risky strategy for controlling weight in adolescents

Paternalism or partnership?: Patients have grown up—and there's no going back

Abstract: Paternalism is endemic in the NHS. Benign and well intentioned it may be, but it has the effect of creating and maintaining an unhealthy dependency which is out of step with other currents in society. Assumptions that doctor (or nurse) knows best, making decisions on behalf of patients without involving them and feeling threatened when patients have access to alternative sources of medical information—these signs of paternalism should have no place in modern health care. The articles assembled in this issue of the BMJ consider the scope for creating meaningful partnerships between doctors and patients and between health policymakers and local communities. Partners work together to achieve common goals. Their relationship is based on mutual respect for each other's skills and competencies and recognition of the advantages of combining these resources to achieve beneficial outcomes. Successful partnerships are non-hierarchical and the partners share decision making and responsibility. The key to successful doctor-patient partnerships is therefore to recognise that patients are experts too.1–3 The doctor is, or should be, well informed about diagnostic techniques, the causes of disease, prognosis, …

Single blind, randomised controlled trial of pelvic floor exercises, electrical stimulation, vaginal cones, and no treatment in management of genuine stress incontinence in women

Abstract: Objective :To compare the effect of pelvic floor exercises, electrical stimulation,vaginal cones, and no treatment for genuine stress incontinence. Design :Stratified, single blind, randomised controlled trial. Setting :Multicentre. Participants : 107 women with clinically and urodynamically proved genuine stress incontinence. Mean (range) age was 49.5 (24-70) years, and mean (range) duration of symptoms 10.8 (1-45) years. Interventions : Pelvic floor exercise (n=25) comprised 8-12 contractions 3 times a day and exercise in groups with skilled physical therapists once a week. The electrical stimulation group (n=25) used vaginal intermittent stimulation with the MS 106 Twin at 50 Hz 30 minutes a day. The vaginal cones group (n=27) used cones for 20 minutes a day. The untreated control group (n=30) was offered the use of a continence guard. Muscle strength was measured by vaginal squeeze pressure once a month. Main outcome measures : Pad test with standardised bladder volume, and self report of severity. Results :Improvement in muscle strength was significantly greater (P=0.03) after pelvic floor exercises (11.0 cm H 2 O (95% confidence interval 7.7 to 14.3) before v 19.2 cm H 2 O (15.3 to 23.1) after) than either electrical stimulation (14.8 cm H 2 O (10.9 to 18.7) v 18.6 cm H 2 O (13.3 to 23.9)) or vaginal cones (11.8 cm H 2 O (8.5 to 15.1) v 15.4 cm H 2 O (11.1 to 19.7)). Reduction in leakage on pad test was greater in the exercise group (−30.2 g; −43.3 to 16.9) than in the electrical stimulation group (−7.4 g; −20.9 to 6.1) and the vaginal cones group (−14.7 g; −27.6 to −1.8). On completion of the trial one participant in the control group, 14 in the pelvic floor exercise group, three in the electrical stimulation group, and two in the vaginal cones group no longer considered themselves as having a problem. Conclusion : Training of the pelvic floor muscles is superior to electrical stimulation and vaginal cones in the treatment of genuine stress incontinence.

Sharing decisions with patients: is the information good enough?

Abstract: Editorial by Richards and Coulter Shared decision making, in which patients and health professionals join in both the process of decision making and ownership of the decision made, is attracting considerable interest as a means by which patients' preferences can be incorporated into clinical decisions.1 When there are several treatment options which may have different effects on the patient's quality of life, there is a strong case for offering patients choice. Their active involvement in decision making may increase the effectiveness of the treatment. Trials are currently under way to test this hypothesis formally, but there are good grounds for optimism. Patients with hypertension benefit if they are allowed to adopt an active rather than a passive role in treatment, 2 3 patients with breast cancer suffer less depression and anxiety if they are treated by doctors who adopt a participative consultation style,4 and patients who are more actively involved in discussions about the management of their diabetes achieve better blood sugar control.5 Patients whose doctors are ignorant of their values and preferences may receive treatment that is inappropriate to their needs.6–8 Patients cannot express informed preferences unless they are given sufficient and appropriate information, including detailed explanations about their condition and the likely outcomes with and without treatment. Yet many report considerable difficulties in obtaining relevant information.9 There are various reasons for this. Health professionals frequently underestimate patients' desire for and ability to cope with information. Consultation times are limited—there is often insufficient time to explain fully the condition and the treatment choices. Health professionals may themselves lack knowledge of treatment options and their effects. A solution to this problem is to ensure that patients have access to written or audiovisual material, to inform themselves and to use in discussion with health …

Heterogeneity of coronary heart disease risk factors in Indian, Pakistani, Bangladeshi, and European origin populations: cross sectional study

Abstract: Objective: To compare coronary risk factors and disease prevalence among Indians, Pakistanis, and Bangladeshis, and in all South Asians (these three groups together) with Europeans. Design: Cross sectional survey. Setting: Newcastle upon Tyne. Participants: 259 Indian, 305 Pakistani, 120 Bangladeshi, and 825 European men and women aged 25-74 years. Main outcome measures: Social and economic circumstances, lifestyle, self reported symptoms and diseases, blood pressure, electrocardiogram, and anthropometric, haematological, and biochemical measurements. Results: There were differences in social and economic circumstances, lifestyles, anthropometric measures and disease both between Indians, Pakistanis, and Bangladeshis and between all South Asians and Europeans. Bangladeshis and Pakistanis were the poorest groups. For most risk factors, the Bangladeshis (particularly men) fared the worst: smoking was most common (57%) in that group, and Bangladeshis had the highest concentrations of triglycerides (2.04 mmol/l) and fasting blood glucose (6.6 mmol/l) and the lowest concentration of high density lipoprotein cholesterol (0.97 mmol/l). Blood pressure, however, was lowest in Bangladeshis. Bangladeshis were the shortest (men 164 cm tall v 170 cm for Indians and 174 cm for Europeans). A higher proportion of Pakistani and Bangladeshi men had diabetes (22.4% and 26.6% respectively) than Indians (15.2%). Comparisons of all South Asians with Europeans hid some important differences, but South Asians were still disadvantaged in a wide range of risk factors Findings in women were similar. Conclusion: Risk of coronary heart disease is not uniform among South Asians, and there are important differences between Indians, Pakistanis, and Bangladeshis for many coronary risk factors. The belief that, except for insulin resistance, South Asians have lower levels of coronary risk factors than Europeans is incorrect, and may have arisen from combining ethnic subgroups and examining a narrow range of factors. Key messages South Asians have more coronary heart disease than Europeans despite apparently lower levels of risk factors This study shows that Indians, Pakistanis and Bangladeshis differ in a wide range of coronary risk factors and combining their data is misleading Among South Asians, Indians were least and Bangladeshis most disadvantaged in a range of coronary risk factors. South Asians were disadvantaged in comparison with Europeans Future research and prevention strategies for coronary heart disease in South Asians should acknowledge a broad range of risk factors, the heterogeneity of these populations, linguistic and cultural needs, and environmental factors

Workplace bullying in NHS community trust: staff questionnaire survey

Abstract: Objectives: To determine the prevalence of workplace bullying in an NHS community trust; to examine the association between bullying and occupational health outcomes; and to investigate the relation between support at work and bullying. Design: Questionnaire survey. Setting: NHS community trust in the south east of England. Subjects: Trust employees. Main outcome measures: Measures included a 20item inventory of bullying behaviours designed for the study, the job induced stress scale, the hospital anxiety and depression scale, the overall job satisfaction scale, the support at work scale, and the propensity to leave scale. Results: 1100 employees returned questionnaires—a response rate of 70%. 421(38%) employees reported experiencing one or more types of bullying in the previous year. 460(42%) had witnessed the bullying of others. When bullying occurred it was most likely to be by a manager. Two thirds of the victims of bullying had tried to take action when the bullying occurred, but most were dissatisfied with the outcome. Staff who had been bullied had significantly lower levels of job satisfaction (mean 10.5(SD 2.7) v 12.2(2.3), P Conclusions: Bullying is a serious problem. Setting up systems for supporting staff and for dealing with interpersonal conflict may have benefits for both employers and staff.

Narrative based medicine: why study narrative?

Abstract: This is the first in a series of five articles on narrative based medicine > One day when Pooh Bear had nothing else to do,he thought he would do something, so he went round to Piglet's house to see what Piglet was doing. It was snowing as hestumped over the white forest track, and he expected to find Piglet warming his toes in front of the fire, but to his surprise he saw that the door was open, and the more he looked inside the more Piglet wasn't there.1 This excerpt from the opening chapter of a well known children's story illustrates a number of features of narrative as a linguistic form. Firstly, it has a finite and longitudinal time sequence—>that is, it has a beginning, a series of unfolding events, and (we anticipate) an ending. Secondly, it presupposes both a narrator and a listener whose different viewpoints affect how the story is told. Thirdly, the narrative is concerned with individuals; rather than simply reporting what they do or what is done to them it concerns how those individuals feel and how people feel about them. Both Pooh Bear, trudging hopefully through the snow, and Piglet, mysteriously absent from his usual place beside the fire, are already characters in the story rather than merely objects in the tale. ![][1] The narrative also provides information that does not pertain simply or directly to the unfolding events. The same sequence of events told by another person to another audience might be presented differently without being any less “true.” This is an important point. In contrast with a list of measurements or a description of the outcome of an experiment, there is no self evident definition of what is relevant or what is irrelevant in a particular narrative. The choice of what to tell … [1]: /embed/graphic-1.gif

What do we mean by partnership in making decisions about treatment

Abstract: For many decades, the dominant approach to making decisions about treatment in the medical encounter has been one of paternalism.1–7 In recent years this model has been challenged by doctors, patients, medical ethicists, and researchers who advocate more of a partnership relation between doctors and patients.2 8–13 The reasons for this challenge have been described in detail elsewhere and include the rise of consumerism and the notion of consumer sovereignty in healthcare decision making; the women's movement with its emphasis on challenging medical authority; the passage of legislation focusing on patients' rights in health care; and small area variations in doctors' practice patterns that seem unrelated to differences in health status.7 Though the first three factors are seen as either contributors to or facilitators of patients' participation in making decisions about health care, the fourth highlights the imprecision or the “art” of medical care14: patients with similar clinical problems may receive different treatments from different doctors, due in part to systematic variations in practice patterns across geographical areas.14 15 The call for doctor-patient partnerships opens up options beyond paternalism for approaching the task of making decisions about treatment. But it also raises new complexities. Because a partnership between patient and doctor can take different forms, it is not intuitively apparent what this model would look like. The Oxford English Dictionary (1995) defines a partner as “a person who shares or takes part with another or others.” This definition leaves several important questions unanswered. For example, does the concept of a partnership imply that both doctor and patient need to share all parts of the decision making process? What is it that both parties are sharing, and to what degree? Who is responsible for determining if a partnership is possible and …

Participatory research maximises community and lay involvement

Abstract: Participatory research attempts to negotiate a balance between developing valid generalisable knowledge and benefiting the community that is being researched and to improve research protocols by incorporating the knowledge and expertise of community members. For many types of research in specific communities, these goals can best be met by the community and researcher collaborating in the research as equals. #### Summary points The knowledge, expertise, and resources of the involved community are often key to successful research Three primary features of participatory research include collaboration, mutual education, and acting on results developed from research questions that are relevant to the community Participatory research is based on a mutually respectful partnership between researchers and communities Partnerships are strengthened by joint development of research agreements for the design, implementation, analysis, and dissemination of results Results of participatory research both have local applicability and are transferable to other communities This integrative review is based on a search of medical, nursing, and social science databases and ethical research codes. The material selected had to be significant theoretical works, source documents, or concrete examples of participatory research. We assessed the texts on the basis of our own experiences as members of Native communities (LEC, MLMcC, CMR) and researchers (WLF, NG, ACM, MLMcC, PLT) in participatory research projects. The preliminary draft was reviewed by a wide range of researchers and community members. The members of the North American Primary Care Research Group reviewed and accepted the final draft as a ploicy statement for participatory research This article summarises that document (the full document can be found at http://views.vcu.edu/views/fap/napcrg98/exec.html). Participatory research began as a movement for social justice in international development settings.1 It was developed to help improve social and economic conditions, to effect change, and to reduce the distrust of the people being studied.2 Although different …

Calculating the number needed to treat for trials where the outcome is time to an event

Abstract: The number of patients who need to be treated to prevent one additional event (number needed to treat; NNT) has become a widely used measure of treatment benefit derived from the results of randomised controlled trials with a binary outcome 1 2 We show how to obtain a number needed to treat for studies where the primary outcome is the time to an event. We consider primarily the situation where there is no access to raw data, for example, when reviewing a published study, and also how to proceed when given the raw data. #### Summary points The number needed to treat is the number of patients who need to be treated to prevent one additional adverse outcome This number (with confidence interval) is a clinically useful way to report the results of controlled trials For any trial which has reported a binary outcome, the number needed to treat can be obtained as the reciprocal of the absolute difference in proportions of patients with the outcome of interest In studies where the outcome of interest is the time to an event, calculations can be extended to show the number needed to treat at any time after the start of treatment As noted previously, for studies with binary outcome the number needed to treat will vary according to the length of follow up.3 For studies of survival this relation with time is more explicit. There is no single number needed to treat; rather it can be calculated at any time point after the start of treatment. Often there are one or two time points of particular clinical interest. A time specific number needed to treat represents the number of patients who need to be given the treatment in question for one additional patient to survive to that time point—that is, to benefit from …