Showing papers in "BMJ in 2001"

Abstract: There is, I think, something ethereal about i —the square root of minus one. I remember first hearing about it at school. It seemed an odd beast at that time—an intruder hovering on the edge of reality. Usually familiarity dulls this sense of the bizarre, but in the case of i it was the reverse: over the years the sense of its surreal nature intensified. It seemed that it was impossible to write mathematics that described the real world in …

Abstract: Crossing the Quality Chasm identifies and recommends improvements in six dimensions of health care in the U.S.: patient safety, care effectiveness, patient-centeredness, timeliness, care efficiency, and equity. Safety looks at reducing the likelihood that patients are harmed by medical errors. Effectiveness describes avoiding over and underuse of resources and services. Patient-centeredness relates both to customer service and to considering and accommodating individual patient needs when making care decisions. Timeliness emphasizes reducing wait times. Efficiency focuses on reducing waste and, as a result, total cost of care. Equity looks at closing racial and income gaps in health care.

Abstract: This is the first in a series of four articles The quality of controlled trials is of obvious relevance to systematic reviews. If the “raw material” is flawed then the conclusions of systematic reviews cannot be trusted. Many reviewers formally assess the quality of primary trials by following the recommendations of the Cochrane Collaboration and other experts. 1 2 However, the methodology for both the assessment of quality and its incorporation into systematic reviews and meta-analysis are a matter of ongoing debate.3-5 In this article we discuss the concept of study quality and the methods used to assess quality. #### Components of internal and external validity of controlled clinical trials Internal validity —extent to which systematic error (bias) is minimised in clinical trials Quality is a multidimensional concept, which could relate to the design, conduct, and analysis of a trial, its clinical relevance, or quality of reporting.6 The validity of the findings generated by a study clearly is an important dimension of quality. In the 1950s the social scientist Campbell proposed a useful distinction between internal and external validity (see box below). 7 8 Internal validity implies that the differences observed between groups of patients allocated to different …

Abstract: Qualitative research methods are enjoying unprecedented popularity. Although checklists have undoubtedly contributed to the wider acceptance of such methods, these can be counterproductive if used prescriptively. The uncritical adoption of a range of “technical fixes” (such as purposive sampling, grounded theory, multiple coding, triangulation, and respondent validation) does not, in itself, confer rigour. In this article I discuss the limitations of these procedures and argue that there is no substitute for systematic and thorough application of the principles of qualitative research. Technical fixes will achieve little unless they are embedded in a broader understanding of the rationale and assumptions behind qualitative research. #### Summary points Checklists can be useful improving qualitative research methods, but overzealous and uncritical use can be counterproductive Reducing qualitative research to a list of technical procedures (such as purposive sampling, grounded theory, multiple coding, triangulation, and respondent validation) is overly prescriptive and results in “the tail wagging the dog” None of these “technical fixes” in itself confers rigour; they can strengthen the rigour of qualitative research only if embedded in a broader understanding of qualitative research design and data analysis Otherwise we risk compromising the unique contribution that systematic qualitative research can make to health services research In medical research the question is no longer whether qualitative methods are valuable but how rigour can be ensured or enhanced. Checklists have played an important role in conferring respectability on qualitative research and in convincing potential sceptics of its thoroughness.1–3 They have equipped those unfamiliar with this approach to evaluate or review qualitative work (by providing guidance on crucial questions that need to be asked) and in reminding qualitative researchers of the need for a systematic approach (by providing an aide-memoire of the various stages involved in research design and data analysis4). Qualitative researchers stress the …

Abstract: This is the first in a series of four articles Across all disciplines, at all levels, and throughout the world, health care is becoming more complex. Just 30 years ago the typical general practitioner in the United Kingdom practised from privately owned premises with a minimum of support staff, subscribed to a single journal, phoned up a specialist whenever he or she needed advice, and did around an hour's paperwork per week. The specialist worked in a hospital, focused explicitly on a particular system of the body, was undisputed leader of his or her “firm,” and generally left administration to the administrators. These individuals often worked long hours, but most of their problems could be described in biomedical terms and tackled using the knowledge and skills they had acquired at medical school. You used to go to the doctor when you felt ill, to find out what was wrong with you and get some medicine that would make you better. These days you are as likely to be there because the doctor (or the nurse, the care coordinator, or even the computer) has sent for you. Your treatment will now be dictated by the evidence—but this may well be imprecise, equivocal, or conflicting. Your declared values and preferences may be used, formally or informally, in a shared management decision about your illness. The solution to your problem is unlikely to come in a bottle and may well involve a multidisciplinary team. Not so long ago public health was the science of controlling infectious diseases by identifying the “cause” (an alien organism) and taking steps to remove or contain it. Today's epidemics have fuzzier boundaries (one is even known as “syndrome X”1): they are the result of the interplay of genetic predisposition, environmental context, and lifestyle choices. The experience of …

Abstract: Objectives: To examine the feasibility of detecting adverse events through record review in British hospitals and to make preliminary estimates of the incidence and costs of adverse events. Design: Retrospective review of 1014 medical and nursing records. Setting: Two acute hospitals in Greater London area. Main outcome measure: Number of adverse events. Results: 110 (10.8%) patients experienced an adverse event, with an overall rate of adverse events of 11.7% when multiple adverse events were included. About half of these events were judged preventable with ordinary standards of care. A third of adverse events led to moderate or greater disability or death. Conclusions: These results suggest that adverse events are a serious source of harm to patients and a large drain on NHS resources. Some are major events; others are frequent, minor events that go unnoticed in routine clinical care but together have massive economic consequences

Abstract: In many randomised trials researchers measure a continuous variable at baseline and again as an outcome assessed at follow up. Baseline measurements are common in trials of chronic conditions where researchers want to see whether a treatment can reduce pre-existing levels of pain, anxiety, hypertension, and the like. Statistical comparisons in such trials can be made in several ways. Comparison of follow up (post-treatment) scores will give a result such as “at the end of the trial, mean pain scores were 15 mm (95% confidence interval 10 to 20 mm) lower in the treatment group.” Alternatively a change score can be calculated by subtracting the follow up score from the baseline score, leading to a statement such as “pain reductions were 20 mm (16 to 24 mm) greater on treatment than control.” If the average baseline scores are the same in each group the estimated treatment effect will be the same using these two simple approaches. If the treatment is effective the statistical significance of the treatment effect by the two methods will depend on the correlation between baseline and follow up scores. If the correlation is low using the change score will …

Abstract: This is the second in a series of four articles Studies that show a significant effect of treatment are more likely to be published, be published in English, be cited by other authors, and produce multiple publications than other studies.1–8 Such studies are therefore also more likely to be identified and included in systematic reviews, which may introduce bias.9 Low methodological quality of studies included in a systematic review is another important source of bias.10 All these biases are more likely to affect small studies than large ones. The smaller a study the larger the treatment effect necessary for the results to be significant. The greater investment of time and money in larger studies means that they are more likely to be of high methodological quality and published even if their results are negative. Bias in a systematic review may therefore become evident through an association between the size of the treatment effect and study size—such associations may be examined both graphically and statistically. #### Summary points Asymmetrical funnel plots may indicate publication bias or be due to exaggeration of treatment effects in small studies of low quality Bias is not the only explanation for funnel plot asymmetry; funnel plots should be seen as a means of examining “small study effects” (the tendency for the smaller studies in a meta-analysis to show larger treatment effects) rather than a tool for diagnosing specific types of bias Statistical methods may be used to examine the evidence for bias and to examine the robustness of the conclusions of the meta-analysis in sensitivity analyses “Correction” of treatment effect estimates for bias should be avoided as such corrections may depend heavily on the assumptions made Multivariable models may be used, with caution, to examine the relative importance of different types of bias ### Funnel plots Funnel …

Abstract: Objective: To examine the relation of midlife raised blood pressure and serum cholesterol concentrations to Alzheimer9s disease in later life Design: Prospective, population based study Setting: Populations of Kuopio and Joensuu, eastern Finland Participants: Participants were derived from random, population based samples previously studied in a survey carried out in 1972, 1977, 1982, or 1987 After an average of 21 years9 follow up, a total of 1449 (73%) participants aged 65–79 took part in the re-examination in 1998 Main outcome measures: Midlife blood pressure and cholesterol concentrations and development of Alzheimer9s disease in later life Results: People with raised systolic blood pressure (≥160 mm Hg) or high serum cholesterol concentration (≥65 mmol/l) in midlife had a significantly higher risk of Alzheimer9s disease in later life, even after adjustment for age, body mass index, education, vascular events, smoking status, and alcohol consumption, than those with normal systolic blood pressure (odds ratio 23, 95% confidence interval 10 to 55) or serum cholesterol (odds ratio 21, 10 to 44) Participants with both of these risk factors in midlife had a significantly higher risk of developing Alzheimer9s disease than those with either of the risk factors alone (odds ratio 35, 16 to 79) Diastolic blood pressure in midlife had no significant effect on the risk of Alzheimer9s disease Conclusion: Raised systolic blood pressure and high serum cholesterol concentration, and in particular the combination of these risks, in midlife increase the risk of Alzheimer9s disease in later life What is already known on this topic Vascular risk factors may play an important part as risk factors for Alzheimer9s disease No population based studies have evaluated prospectively the impact of both midlife blood pressure and cholesterol concentration in both men and women on the subsequent development of Alzheimer9s disease What this study adds Raised systolic blood pressure and high serum cholesterol concentration, and in particular the combination of these risks, in midlife increased the risk of Alzheimer9s disease in later life Raised systolic blood pressure and hypercholesterolaemia may have a role in the pathogenesis of Alzheimer9s disease; more emphasis should be placed on identification and appropriate treatment of these conditions

Abstract: The Scottish Intercollegiate Guidelines Network (SIGN) develops evidence based clinical guidelines for the NHS in Scotland. The key elements of the methodology are (a) that guidelines are developed by multidisciplinary groups; (b) they are based on a systematic review of the scientific evidence; and (c) recommendations are explicitly linked to the supporting evidence and graded according to the strength of that evidence. Until recently, the system for grading guideline recommendations was based on the work of the US Agency for Healthcare Research and Quality (formerly the Agency for Health Care Policy and Research). 1 2 However, experience over more than five years of guideline development led to a growing awareness of this system's weaknesses. Firstly, the grading system was designed largely for application to questions of effectiveness, where randomised controlled trials are accepted as the most robust study design with the least risk of bias in the results. However, in many areas of medical practice randomised trials may not be practical or ethical to undertake; and for many questions other types of study design may provide the best evidence. Secondly, guideline development groups often fail to take adequate account of the methodological quality of individual studies and the overall picture presented by a body of evidence rather than individual studies or they fail to apply sufficient judgment to the overall strength of the evidence base and its applicability to the target population of the guideline. Thirdly, guideline users are often not clear about the implications of the grading system. They misinterpret the grade of recommendation as relating to its importance, rather than to the strength of the supporting evidence, and may therefore fail to give due weight to low grade recommendations. #### Summary points A revised system of determining levels of evidence and grades …

Abstract: The findings of medical research are often met with considerable scepticism, even when they have apparently come from studies with sound methodologies that have been subjected to appropriate statistical analysis. This is perhaps particularly the case with respect to epidemiological findings that suggest that some aspect of everyday life is bad for people. Indeed, one recent popular history, the medical journalist James Le Fanu's The Rise and Fall of Modern Medicine , went so far as to suggest that the solution to medicine's ills would be the closure of all departments of epidemiology.1 One contributory factor is that the medical literature shows a strong tendency to accentuate the positive; positive outcomes are more likely to be reported than null results.2–4 By this means alone a host of purely chance findings will be published, as by conventional reasoning examining 20 associations will produce one result that is “significant at P=0.05” by chance alone. If only positive findings are published then they may be mistakenly considered to be of importance rather than being the necessary chance results produced by the application of criteria for meaningfulness based on statistical significance. As many studies contain long questionnaires collecting information on hundreds of variables, and measure a wide range of potential outcomes, several false positive findings are virtually guaranteed. The high volume and often contradictory nature5 of medical research findings, however, is not only because of publication bias. A more fundamental problem is the widespread misunderstanding of the nature of statistical significance. #### Summary points P values, or significance levels, measure the strength of the evidence against the null hypothesis; the smaller the P value, the stronger the evidence against the null hypothesis An arbitrary division of results, into “significant” or “non-significant” according to the P value, was not the intention of the …

Abstract: This is the third in a series of four articles Tests are routinely used in medicine to screen for, diagnose, grade, and monitor the progression of disease. Diagnostic information is obtained from a multitude of sources, including imaging and biochemical technologies, pathological and psychological investigations, and signs and symptoms elicited during history taking and clinical examinations.1 Each of these items of information can be regarded as a result of a separate diagnostic or screening “test.” Systematic reviews of evaluations of tests are undertaken for the same reasons as systematic reviews of treatment interventions: to produce estimates of test performance and impact based on all available evidence, to evaluate the quality of published studies, and to account for variation in findings between studies.2–5 Reviews of studies of diagnostic accuracy involve the same key stages of defining questions, searching the literature, evaluating studies for eligibility and quality, and extracting and synthesising data. However, studies that evaluate the accuracy of tests have a unique design requiring different criteria to appropriately assess the quality of studies and the potential for bias. Additionally, each study reports a pair of related summary statistics (for example, sensitivity and specificity) rather than a single statistic (such as a risk ratio) and hence requires different statistical methods to pool the results of the studies. This article concentrates on the dimensions of study quality and the advantages and disadvantages of different summary statistics for combining studies in meta-analysis. Other aspects, including searching the literature and further technical details, are discussed elsewhere.6 #### Summary points Systematic reviews of studies of diagnostic accuracy differ from other systematic reviews in the assessment of study quality and the statistical methods used to combine results Important aspects of study quality include the selection of a clinically relevant cohort, the consistent use of a …

Abstract: Objective: To follow mothers9 mood through pregnancy and after childbirth and compare reported symptoms of depression at each stage. Design: Longitudinal cohort study. Setting: Avon. Participants: Pregnant women resident within Avon with an expected date of delivery between 1 April 1991 and 31 December 1992. Main outcome measures: Symptom scores from the Edinburgh postnatal depression scale at 18 and 32 weeks of pregnancy and 8 weeks and 8 months postpartum. Proportion of women above a threshold indicating probable depressive disorder. Results: Depression scores were higher at 32 weeks of pregnancy than 8 weeks postpartum (difference in means 0.88, 95% confidence interval 0.79 to 0.97). There was no difference in the distribution of total scores or scores for individual items at the four time points. 1222 (13.5%) women scored above threshold for probable depression at 32 weeks of pregnancy, 821 (9.1%) at 8 weeks postpartum, and 147 (1.6%) throughout. More mothers moved above the threshold for depression between 18 weeks and 32 weeks of pregnancy than between 32 weeks of pregnancy and 8 weeks postpartum. Conclusions: Symptoms of depression are not more common or severe after childbirth than during pregnancy. Research and clinical efforts need to be moved towards understanding, recognising, and treating antenatal depression.

Abstract: Objective: To determine how growth during infancy and childhood modifies the increased risk of coronary heart disease associated with small body size at birth. Design: Longitudinal study. Setting: Helsinki, Finland. Subjects: 4630 men who were born in the Helsinki University Hospital during 1934–44 and who attended child welfare clinics in the city. Each man had on average 18.0 (SD 9.5) measurements of height and weight between birth and age 12 years. Main outcome measures: Hospital admission or death from coronary heart disease. Results: Low birth weight and low ponderal index (birth weight/length3) were associated with increased risk of coronary heart disease. Low height, weight, and body mass index (weight/height2) at age 1 year also increased the risk. Hazard ratios fell progressively from 1.83 (95% confidence interval 1.28 to 2.60) in men whose body mass index at age 1 year was below 16 kg/m2 to 1.00 in those whose body mass index was >19 (P for trend=0.0004). After age 1 year, rapid gain in weight and body mass index increased the risk of coronary heart disease. This effect was confined, however, to men with a ponderal index Conclusion: Irrespective of size at birth, low weight gain during infancy is associated with increased risk of coronary heart disease. After age 1 year, rapid weight gain is associated with further increase in risk, but only among boys who were thin at birth. In these boys the adverse effects of rapid weight gain on later coronary heart disease are already apparent at age 3 years. Improvements in fetal, infant, and child growth could lead to substantial reductions in the incidence of coronary heart disease. What is already known on this topic Coronary heart disease is associated with low birth weight One study has shown that irrespective of size at birth, low weight gain in infancy is also associated with increased risk of the disease among men Rapid weight gain after age 6 years is associated with further increase in risk What this study adds The association with low weight gain in infancy is confirmed The adverse effects of rapid childhood weight gain on risk of coronary heart disease are already apparent at age 3 years and occur only in boys who were thin at birth

Abstract: Objective: To determine the effectiveness of exercise as an intervention in the management of depression. Design: Systematic review and meta-regression analysis of randomised controlled trials obtained from five electronic databases (Medline, Embase, Sports Discus, PsycLIT, Cochrane Library) and through contact with experts in the field, bibliographic searches, and hand searches of recent copies of relevant journals. Main outcome measures: Standardised mean difference in effect size and weighted mean difference in Beck depression inventory score between exercise and no treatment and between exercise and cognitive therapy. Results: All of the 14 studies analysed had important methodological weaknesses; randomisation was adequately concealed in only three studies, intention to treat analysis was undertaken in only two, and assessment of outcome was blinded in only one. The participants in most studies were community volunteers, and diagnosis was determined by their score on the Beck depression inventory. When compared with no treatment, exercise reduced symptoms of depression (standardised mean difference in effect size −1.1 (95% confidence interval −1.5 to −0.6); weighted mean difference in Beck depression inventory −7.3 (−10.0 to −4.6)). The effect size was significantly greater in those trials with shorter follow up and in two trials reported only as conference abstracts. The effect of exercise was similar to that of cognitive therapy (standardised mean difference −0.3 (95% confidence interval −0.7 to 0.1)). Conclusions: The effectiveness of exercise in reducing symptoms of depression cannot be determined because of a lack of good quality research on clinical populations with adequate follow up. What is already known on this topic Depression is common Management is often inadequate and many patients do not comply with antidepressant medication The effect of exercise on depression has been a subject of interest for many years What this study adds Most studies of the effect of exercise on depression are of poor quality, have brief follow up, and are undertaken on non-clinical volunteers Exercise may be efficacious in reducing symptoms of depression in the short term but its effectiveness in clinical populations is unknown A well designed, randomised controlled trial with long term follow up is needed

Abstract: Objective To examine the value of glycated haemoglobin (HbA1c) concentration, a marker of blood glucose concentration, as a predictor of death from cardiovascular and all causes in men. Design Prospective population study. Setting Norfolk cohort of European Prospective Investigation into Cancer and Nutrition (EPIC›Norfolk). Subjects 4662 men aged 45›79 years who had had glycated haemoglobin measured at the baseline survey in 1995›7 who were followed up to December 1999. Main outcome measures Mortality from all causes, cardiovascular disease, ischaemic heart disease, and other causes. Results Men with known diabetes had increased mortality from all causes, cardiovascular disease, and ischaemic disease (relative risks 2.2, 3.3, and 4.2, respectively, P < 0.001 independent of age and other risk factors) compared with men without known diabetes. The increased risk of death among men with diabetes was largely explained by HbA1c concentration. HbA1c was continuously related to subsequent all cause, cardiovascular, and ischaemic heart disease mortality through the whole population distribution, with lowest rates in those with HbA1c concentrations below 5%. An increase of 1% in HbA1c was associated with a 28% (P < 0.002) increase in risk of death independent of age, blood pressure, serum cholesterol, body mass index, and cigarette smoking habit; this effect remained (relative risk 1.46, P = 0.05

Abstract: Objective: To assess whether mothers and fathers have a higher long term risk of death, particularly from cardiovascular disease and cancer, after the mother has had pre-eclampsia. Design: Population based cohort study of registry data. Subjects: Mothers and fathers of all 626 272 births that were the mothers9 first deliveries, recorded in the Norwegian medical birth registry from 1967 to 1992. Parents were divided into two cohorts based on whether the mother had pre-eclampsia during the pregnancy. Subjects were also stratified by whether the birth was term or preterm, given that pre-eclampsia might be more severe in preterm pregnancies. Main outcome measures: Total mortality and mortality from cardiovascular causes, cancer, and stroke from 1967 to 1992, from data from the Norwegian registry of causes of death. Results: Women who had pre-eclampsia had a 1.2-fold higher long term risk of death (95% confidence interval 1.02 to 1.37) than women who did not have pre-eclampsia. The risk in women with pre-eclampsia and a preterm delivery was 2.71-fold higher (1.99 to 3.68) than in women who did not have pre-eclampsia and whose pregnancies went to term. In particular, the risk of death from cardiovascular causes among women with pre-eclampsia and a preterm delivery was 8.12-fold higher (4.31 to 15.33). However, these women had a 0.36-fold (not significant) decreased risk of cancer. The long term risk of death was no higher among the fathers of the pre-eclamptic pregnancies than the fathers of pregnancies in which pre-eclampsia did not occur. Conclusions: Genetic factors that increase the risk of cardiovascular disease may also be linked to pre-eclampsia. A possible genetic contribution from fathers to the risk of pre-eclampsia was not reflected in increased risks of death from cardiovascular causes or cancer among fathers. What is already known on this topic Maternal and fetal genes (including those inherited from the father) may contribute to pre-eclampsia, which occurs in 3-5% of pregnancies One set of candidate genes for pre-eclampsia is the maternal genes for thrombophilia, which may increase the mother9s risk of death from cardiovascular disease What this study adds Women who have pre-eclampsia during a pregnancy that ends in a preterm delivery have an eightfold higher risk of death from cardiovascular disease compared with women who do not have pre-eclampsia and whose pregnancy goes to term Fathers of pregnancies in which pre-eclampsia occurred have no increased risk of death from cardiovascular disease These results are compatible with maternal genes for thrombophilia having an effect on the risk of pre-eclampsia and of death from cardiovascular disease

Abstract: Primary care p 468 Key messages about patient centred care can be drawn from the paper by Little et al in this issue of the BMJ (p 468).1 Firstly, strong agreement exists between the definition of patient centredness that arises empirically from this observational study of patients in the United Kingdom and another definition arising from reflections on practice in South Africa and Canada,2 suggesting an international definition of patient centred medicine. Secondly, the premise of the observational study is correct—that the best way of measuring patient centredness is an assessment made by the patients themselves. Patient centredness is becoming a widely used, but poorly understood, concept in medical practice. It may be most commonly understood for what it is not—technology centred, doctor centred, hospital centred, disease centred. Definitions of patient centred care seek to make the implicit in patient care explicit. Such definitions are, we recognise, oversimplifications which help in teaching and research but fail to capture the indivisible whole of a healing relationship. Perhaps qualitative research comes closer to conveying the qualities of such care. Acknowledging these limitations, researchers seek answers to crucial questions …

Abstract: In December 2000 Nottingham University announced the establishment of an international centre for corporate social responsibility, with initial funding of £3.8m provided by British American Tobacco (BAT). To protest aganst their university's acceptance of money from the tobacco industry, an MBA student refused to accept his “student of the year” award; Richard Smith, editor of the BMJ , resigned from his post as professor of medical journalism; a cancer research team decided to relocate; and a member of the European parliament relinquished her roles at the university. Nottingham joins a long list of universities that have accepted funding from the tobacco industry. Other academic institutions have, however, taken the opposite stance and severed their ties with this industry. For example, Brigham and Women's and Massachusetts General hospitals in Boston, the MD Anderson Cancer Center in Houston, the Roswell Park Cancer Institute in Buffalo, and the University of Sydney all have policies precluding acceptance of research funds from the tobacco industry.1 The …

Abstract: Patient centeredness is becoming a widely used but poorly understood concept in medical practice. Definitions of patient-centered care are oversimplifications that help in teaching and research but fail to capture the invisible whole of a healing relationship. Acknowledging these limitations researchers seek answers to crucial questions about patient-centered medicine. Little et al. focus on the questions of what constitutes a patient-centered care approach and whether patients want it. Overall their results indicate that patients do want patient-centered care that 1) explores the patients main reason for the visit concerns and need for information; 2) seeks an integrated understanding of the patients emotional needs and life issues; 3) finds common ground on what the problem is and mutually agrees on management; 4) enhances prevention and health promotion; and 5) enhances the continuing relationship between the patient and the doctor. Other papers on patient perceptions of patient centeredness confirm these findings. However two common misunderstandings about the approach may be perpetuated by Little et al.s study. First they cite concerns that patients may not prefer a patient-centered approach and hence its universal adoption would be unwise. Second the basic question of Little et al.s study implies that patient-centered care can be neatly separated into divisible parts.

Abstract: Objective: To assess the effect of multidisciplinary biopsychosocial rehabilitation on clinically relevant outcomes in patients with chronic low back pain Design: Systematic literature review of randomised controlled trials Participants: A total of 1964 patients with disabling low back pain for more than three months Main outcome measures: Pain, function, employment, quality of life, and global assessments Results: Ten trials reported on a total of 12 randomised comparisons of multidisciplinary treatment and a control condition There was strong evidence that intensive multidisciplinary biopsychosocial rehabilitation with functional restoration improves function when compared with inpatient or outpatient non-multidisciplinary treatments There was moderate evidence that intensive multidisciplinary biopsychosocial rehabilitation with functional restoration reduces pain when compared with outpatient non-multidisciplinary rehabilitation or usual care There was contradictory evidence regarding vocational outcomes of intensive multidisciplinary biopsychosocial intervention Some trials reported improvements in work readiness, but others showed no significant reduction in sickness leaves Less intensive outpatient psychophysical treatments did not improve pain, function, or vocational outcomes when compared with non-multidisciplinary outpatient therapy or usual care Few trials reported effects on quality of life or global assessments Conclusions: The reviewed trials provide evidence that intensive multidisciplinary biopsychosocial rehabilitation with functional restoration reduces pain and improves function in patients with chronic low back pain Less intensive interventions did not show improvements in clinically relevant outcomes What is already known on this topic Disabling chronic pain is regarded as the result of interrelating physical, psychological, and social or occupational factors requiring multidisciplinary intervention Two previous systematic reviews of multidisciplinary rehabilitation for chronic pain were open to bias and did not include any of the randomised controlled trials now available What this study adds Intensive, daily biopsychosocial rehabilitation with a functional restoration approach improves pain and function in chronic low back pain Less intensive interventions did not show improvements in clinically relevant outcomes It is unclear whether the improvements are worth the cost of these intensive treatments

Abstract: Objectives: To establish the relation between recurrent peer victimisation and onset of self reported symptoms of anxiety or depression in the early teen years. Design: Cohort study over two years. Setting: Secondary schools in Victoria, Australia. Participants: 2680 students surveyed twice in year 8 (aged 13 years) and once in year 9. Main outcome measures: Self reported symptoms of anxiety or depression were assessed by using the computerised version of the revised clinical interview schedule. Incident cases were students scoring ≥12 in year 9 but not previously. Prior victimisation was defined as having been bullied at either or both survey times in year 8. Results: Prevalence of victimisation at the second survey point in year 8 was 51% (95% confidence interval 49% to 54%), and prevalence of self reported symptoms of anxiety or depression was 18% (16% to 20%). The incidence of self reported symptoms of anxiety or depression in year 9 (7%) was significantly associated with victimisation reported either once (odds ratio 1.94, 1.1 to 3.3) or twice (2.30, 1.2 to 4.3) in year 8. After adjustment for availability of social relations and for sociodemographic factors, recurrent victimisation remained predictive of self reported symptoms of anxiety or depression for girls (2.60, 1.2 to 5.5) but not for boys (1.36, 0.6 to 3.0). Newly reported victimisation in year 9 was not significantly associated with prior self report of symptoms of anxiety or depression (1.48, 0.4 to 6.0). Conclusion: A history of victimisation and poor social relationships predicts the onset of emotional problems in adolescents. Previous recurrent emotional problems are not significantly related to future victimisation. These findings have implications for how seriously the occurrence of victimisation is treated and for the focus of interventions aimed at addressing mental health issues in adolescents. What is already known on this topic Being bullied is a common experience for many young people Victimisation is related to depression and, to a lesser extent, anxiety, loneliness, and general self esteem Debate remains as to whether victimisation precedes the onset of emotional problems or whether young people with emotional problems “invite” victimisation What this study adds A history of victimisation predicts the onset of anxiety or depression, especially in adolescent girls Previous recurrent emotional problems are not significantly related to future victimisation Reduction in bullying in schools could have a substantial impact on the emotional wellbeing of young people

Abstract: Objective: To measure patients9 perceptions of patient centredness and the relation of these perceptions to outcomes. Design: Observational study using questionnaires. Setting: Three general practices. Participants: 865 consecutive patients attending the practices. Main outcome measures: Patients9 enablement, satisfaction, and burden of symptoms. Results: Factor analysis identified five components. These were communication and partnership (a sympathetic doctor interested in patients9 worries and expectations and who discusses and agrees the problem and treatment, Cronbach9s α=0.96); personal relationship (a doctor who knows the patient and their emotional needs, α=0.89); health promotion (α=0.87); positive approach (being definite about the problem and when it would settle, α=0.84); and interest in effect on patient9s life (α=0.89). Satisfaction was related to communication and partnership (adjusted β=19.1; 95% confidence interval 17.7 to 20.7) and a positive approach (4.28; 2.96 to 5.60). Enablement was greater with interest in the effect on life (0.55; 0.25 to 0.86), health promotion (0.57; 0.30 to 0.85), and a positive approach (0.82; 0.52 to 1.11). A positive approach was also associated with reduced symptom burden at one month (β=−0.25; −0.41 to −0.10). Referrals were fewer if patients felt they had a personal relationship with their doctor (odds ratio 0.70; 0.54 to 0.90). Conclusions: Components of patients9 perceptions can be measured reliably and predict different outcomes. If doctors don9t provide a positive, patient centred approach patients will be less satisfied, less enabled, and may have greater symptom burden and higher rates of referral. What is already known on this topic Preliminary evidence suggests that patients9 perceptions of patient centredness predict outcomes better than analysing what the doctor says in a consultation What this study adds There are five distinct components of patients9 perceptions that can be measured reliably: communication and partnership, personal relationship, health promotion, positive approach to diagnosis and prognosis, and interest in the effect on life Each component predicts different consultation outcomes If doctors don9t provide a positive, patient centred approach patients will be less satisfied, less enabled, and may have greater symptom burden and use more health service resources

Abstract: There is a large market for blood pressure measuring devices not only in clinical medicine but also among the public where the demand for self measurement of blood pressure is growing rapidly. For consumers, whether medical or lay, accuracy should be of prime importance when selecting a device to measure blood pressure. However, most devices have not been evaluated for accuracy independently using the two most widely used protocols: the British Hypertension Society (BHS) protocol and the standard set by the US Association for the Advancement of Medical Instrumentation (AAMI). 1 2 The Working Group on Blood Pressure Monitoring of the European Society of Hypertension has decided to review blood pressure measuring devices regularly to guide purchasers.3 For this first report devices for which there is published evidence of independent validation using these protocols have been surveyed. Because most blood pressure devices have not been independently validated, only a fraction of the many devices available have been surveyed. Devices that have been validated recently for which results have not yet been published were not included, but this shortcoming should be addressed in future. #### Summary points Two manual sphygmomanometers have been validated, one is recommended Five devices for clinical use in hospitals have been validated, two are recommended 23 devices for self measurement of blood pressure have been validated, five are recommended 24 devices for ambulatory measurement of blood pressure have been validated, 16 are recommended Validations and recommendations will be updated on the BMJ 's website ### Validation standards In 1987, the American Association for the Advancement of Medical Instrumentation published a standard for sphygmomanometers which included a protocol for evaluating the accuracy of devices.4 In 1990 a protocol was devised by the British Hypertension Society.5 Both protocols have since been revised. 1 2 Since the two protocols can be reconciled the …

Abstract: This is the second in a series of five articles In modern medicine the traditional way of assessing change in patients has been to focus on laboratory or clinical tests. At its most simple this involves measuring pulse, blood pressure, and temperature, and carrying out physical examinations. At more complex levels it may include haematological analysis, computed tomography, radiography, organ function tests, genetic analysis, and other investigations. While these give important information about the disease, especially about chronic and progressive diseases, it is impossible to separate disease from an individual's personal and social context. No illness exists in a vacuum. One way of capturing the personal and social context of patients is to use quality of life measures.1 These are accepted as outcome measures in clinical research but are rarely used in routine clinical practice, despite the fact that Florence Nightingale was one of the first clinicians to insist on measuring the outcome of routine care to evaluate treatment.2 This article reviews the challenges of using quality of life measures in clinical practice including selecting appropriate measures, analysing data, providing feedback, interpreting results, and incorporating these measures into clinical decision making. Practical ways of resolving the tension between the need for approaches suitable in the clinical encounter and the highly individualised nature of quality of life are also examined. #### Summary points Using quality of life measures in clinical practice ensures that treatment and evaluations focus on the patient rather than the disease The measures are potentially useful in both the clinical encounter and in quality improvement They are not a substitute for measures of disease outcomes and may not always be the most appropriate patient centred outcome to assess Measures developed for research often cannot easily be used in clinical practice Measures that form an integral part of treatment planning …

Abstract: Editorial by Little and Byrne It is generally accepted that obesity is a health hazard because of its association with numerous metabolic complications such as dyslipidaemia, type 2 diabetes, and cardiovascular diseases.1 On that basis, health agencies 2 3 have proposed that obesity should be defined on the basis of weight in kg expressed over height in m2, the so called body mass index,4 initially described by Quetelet in 1869 (table). Epidemiological studies have reported a progressive increase in the incidence of chronic diseases such as hypertension, diabetes, and coronary heart disease with increasing body mass index.1-3 However, despite this well documented evidence, physicians are, in their daily practice, perplexed by the remarkable heterogeneity found in their obese patients. For instance, some patients show a relatively “normal” profile of metabolic risk factors despite the presence of substantial excess body fat, whereas others who are only moderately overweight can nevertheless be characterised by a whole cluster of metabolic complications, increasing the risk of type 2 diabetes, coronary atherosclerosis, and cardiovascular disease. View this table: Classification of obesity based on body mass index (BMI)2 3 #### Summary points A simple measurement such as waist circumference can indicate accumulation of abdominal fat Viscerally obese men are characterised by an atherogenic plasma lipoprotein profile A triad of non-traditional markers for coronary heart disease found in viscerally obese middle aged men (hyperinsulinaemia, raised apolipoprotein B concentration, and small LDL particles) increases the risk of coronary heart disease 20-fold Four out of five middle aged men with a waist measurement ≥90 cm and triglyceride concentrations ≥2 mmol/l are characterised by this triad Even in the absence of hypercholesterolaemia, hyperglycaemia, or hypertension, obese patients could be at high risk of coronary heart disease if they have this “hypertriglyceridaemic waist” phenotype In this regard, epidemiological and metabolic studies …

Abstract: Objective: To determine whether a period of starvation (nil by mouth) after gastrointestinal surgery is beneficial in terms of specific outcomes. Design: Systematic review and meta-analysis of randomised controlled trials comparing any type of enteral feeding started within 24 hours after surgery with nil by mouth management in elective gastrointestinal surgery. Three electronic databases (PubMed, Embase, and the Cochrane controlled trials register) were searched, reference lists checked, and letters requesting details of unpublished trials and data sent to pharmaceutical companies and authors of previous trials. Main outcome measures: Anastomotic dehiscence, infection of any type, wound infection, pneumonia, intra-abdominal abscess, length of hospital stay, and mortality. Results: Eleven studies with 837 patients met the inclusion criteria. In six studies patients in the intervention group were fed directly into the small bowel and in five studies patients were fed orally. Early feeding reduced the risk of any type of infection (relative risk 0.72, 95% confidence interval 0.54 to 0.98, P=0.036) and the mean length of stay in hospital (number of days reduced by 0.84, 0.36 to 1.33, P=0.001). Risk reductions were also seen for anastomotic dehiscence (0.53, 0.26 to 1.08, P=0.080), wound infection, pneumonia, intra-abdominal abscess, and mortality, but these failed to reach significance (P>0.10). The risk of vomiting was increased among patients fed early (1.27, 1.01 to 1.61, P=0.046). Conclusions: There seems to be no clear advantage to keeping patients nil by mouth after elective gastrointestinal resection. Early feeding may be of benefit. An adequately powered trial is required to confirm or refute the benefits seen in small trials. What is already known on this topic Enteral feeding within 24 hours after gastrointestinal surgery is tolerated Theoretically, early enteral feeding improves tissue healing and reduces septic complications after gastrointestinal surgery What this study adds There is no benefit in keeping patients “nil by mouth” after gastrointestinal surgery Septic complications and length of hospital stay were reduced in those patients who received early enteral feeding In patients who received early enteral feeding there were no significant reductions in incidence of anastomotic dehiscence, wound infection, pneumonia, intra-abdominal abscess, and mortality

Abstract: See also Editorial by Catchpole Rates of sexually transmitted diseases are increasing, particularly in people aged between 15 and 25. How best to tackle this increase is unresolved, although several tests have recently been developed that are providing new opportunities for screening, early detection, and prevention of sexually transmitted infections and their complications, particularly for Chlamydia trachomatis , herpes simplex virus, and human papillomavirus. Already these tests are being used in research studies, but their introduction into clinical practice raises complex issues. This articles describes the tests that are now available for the major sexually transmitted infections and discusses the important issues they raise in the management of those diseases. We selected topics for inclusion by reviewing specialist journals and conference abstracts from 1998 to 2000. We chose areas that were the subject of most research reports and that are having a direct impact on patient care. We performed a search of Medline for the same period, based on keywords related to these topics. Earlier references were among those quoted in the publications retrieved by the systematic search. We have not considered advances in HIV disease and its management. In the United Kingdom most cases of sexually transmitted infections are treated at genitourinary medicine clinics. Surveillance data from these clinics show that their workload is steadily increasing (fig 1). There has been a noticeable increase in the number of cases of bacterial infections, particularly chlamydia and gonorrhoea since 1995.1 Chlamydia trachomatis is the most commonly diagnosed bacterial sexually transmitted infection in the developed world and a leading cause of pelvic inflammatory disease.2 In 1999, 56 855 patients with uncomplicated chlamydial infection were seen at UK clinics dealing with genitourinary medicine, an increase of 61% since 1996.1 Given the potential for morbidity from ectopic pregnancy and tubal infertility …

Abstract: Objectives: To compare the cumulative costs of public services used through to adulthood by individuals with three levels of antisocial behaviour in childhood. Design: Costs applied to data of 10 year old children from the inner London longitudinal study selectively followed up to adulthood. Setting: Inner London borough. Participants: 142 individuals divided into three groups in childhood: no problems, conduct problems, and conduct disorder. Main outcome measures: Costs in 1998 prices for public services (excluding private, voluntary agency, indirect, and personal costs) used over and above basic universal provision. Results: By age 28, costs for individuals with conduct disorder were 10.0 times higher than for those with no problems (95% confidence interval of bootstrap ratio 3.6 to 20.9) and 3.5 times higher than for those with conduct problems (1.7 to 6.2). Mean individual total costs were £70 019 for the conduct disorder group (bootstrap mean difference from no problem group £62 898; £22 692 to £117 896) and £24 324 (£16 707; £6594 to £28 149) for the conduct problem group, compared with £7423 for the no problem group. In all groups crime incurred the greatest cost, followed by extra educational provision, foster and residential care, and state benefits; health costs were smaller. Parental social class had a relatively small effect on antisocial behaviour, and although substantial independent contributions came from being male, having a low reading age, and attending more than two primary schools, conduct disorder still predicted the greatest cost. Conclusions: Antisocial behaviour in childhood is a major predictor of how much an individual will cost society. The cost is large and falls on many agencies, yet few agencies contribute to prevention, which could be cost effective. What is already known on this topic Children who show substantial antisocial behaviour have poor social functioning as adults and are at high risk of social exclusion Costs are available for particular items of public service such as receiving remedial education or appearing in court What this study adds Costs of antisocial behaviour incurred by individuals from childhood to adulthood were 10 times greater for those who were seriously antisocial in childhood than for those who were not The costs fell on a wide range of agencies Reduction of antisocial behaviour in childhood could result in large cost savings