Atlheltes with marked ECG repolarizacion abnormalities


Pelliccia A, Di Paolo FM, Quattrini FM, Basso C, Culasso F, Popoli G et alOutcomes in Athletes with Marked ECG Repolarization Abnormalities. N Engl J Med 2008; 358: 152-161.   TC   PDF

Introducción

Los deportistas presentan alteraciones ECG parecidas a las de la HVI. Estas consisten habitualmente en ondas R o S pronunciadas, pero en ocasiones también presentan T invertidas y profundas. Se desconoce si estas alteraciones de la repolarización son indicativas de alguna cardiomiopatía subyacente.

Objetivo

Evaluar los resultados clínicos asociados a la presencia de trastornos de la repolarización en atletas jóvenes.

Perfil del estudio

Tipo de estudio: Estudio de cohortes
Área del estudio: Pronóstico
Ámbito del estudio: Comunitario

Métodos

En Italia es obligatorio desde hace 25 años que todos los participantes en competiciones oficiales pasen un examen médico y un ECG previo a las mismas. Los deportistas que forman parte de las selecciones nacionales y aquellos a los que se les detectan anomalías electrocardiográficas son atendidos en el Instituto de Ciencia y Medicina de los Deportes, donde se lleva a cabo un estudio que incluye un ECG convencional, una prueba de esfuerzo y un ecocardiograma.
Se revisó la base de datos de los deportistas atendidos en este Instituto entre 1979 y 2001 y se identificaron los que presentaban trastornos de la repolarización importantes (ondas T negativas ≥2 mm en ≥3 derivaciones excepto en DIII y predominantemente en las derivaciones V2-V6). Se excuyó a los que tenían evidencia de lesiones estructurales en el ecocardiograma inicial. Como controles se seleccionaron deportistas entre los 20 siguientes a cada uno de los casos con ECG normal apareados por edad, sexo y duración del seguimiento.

Resultados

Se incluyeron en el grupo de casos 81 deportistas (fig. 1). Para ellos se seleccionaron 229 controles que fueron seguidos durante el mismo periodo de tiempo. En el 67% de los casos se detectaron más alteraciones ECG, entre las que destacaban incrementos de los voltajes de las R o las S (52%) y Q profundas (10%). No se apreciaron diferencias entre los casos y los controles. La edad media de los participantes era de 22 años y el 71% eran varones. Los deportes en los que participaban más frecuentemente eran remo, fútbol y waterpolo. El seguimiento medio fue de 9 años. Al final del periodo de seguimiento, el 78% seguían haciendo deporte regularmente, un 21% habían abandonado la práctica deportiva y 1 de los individuos había muerto.
Durante el seguimiento, las alteraciones de la repolarización se mantuvieron inalteradas en el 67% de los individuos, mejoraron en el 18% (menos derivaciones o menor profundidad de las ondas T) y se normalizaron en el 15% restante. En ninguno de los deportistas se apreciaron cambios en el volumen ventricular.
En 11 deportistas con alteraciones de la repolarización se detectaron cardiopatías en el seguimiento (14%). Uno murió a los 24 años un año después de la valoración inicial por una cardiomiopatía ventricular derecha arritmogénica que no se había detectado. En 3 se detectó una cardiomiopatía hipertrófica y en uno una cardiomiopatía dilatada. Uno de los individuos con cardiomiopatía hipertrófica sufrió un paro cardiorrespiratorio del que se recuperó. Otros 6 pacientes del grupo con alteraciones de la repolarización desarrollaron enfermedades cardiovasculares (3 HTA , 1 cardiopatía isquémica que requirió revascularización, 1 miocarditis y 1 taquicardia supraventricular paroxística que requirió ablación). En todos los deportistas que presentaron cardiomiopatías las anomalías ECG se mantuvieron a lo largo de todo el seguimiento.
Ninguno de los controles desarrolló una cardiomiopatía y sólo 4 desarrollaron algún trastorno cardiovascular: 2 taquicardia supraventricular, 1 miocarditis y 1 pericarditis.

Conclusiones

Los autores concluyen que las alteraciones ECG en deportistas jóvenes y aparentemente sanos pueden ser un indicio de cardiomiopatías subyacentes que pueden no hacerse evidentes hasta años más tarde, por lo que deben ser objeto de vigilancia clínica.

Conflictos de interés

Ninguno declarado. Financiado por el Comité Olímpico Italiano.

Comentario

La práctica habitual de deporte (no deporte de élite) tiene consecuencias cardiovasculares beneficiosas. Sin embargo, no es excepcional que en el deporte de élite se den casos de muerte súbita en el transcurso de una prueba deportiva. Se ha demostrado que un programa de cribado preparticipación disminuye el riesgo de estos accidentes.
En el corazón de las personas entrenadas se desarrollan unos cambios que se conocen como el corazón del deportista. Entre ellos destacan el aumento del tamaño y del volumen de las cavidades cardíacas, en especial del ventrículo izquierdo. Fruto de estos cambios, un 40% de los deportistas presentan alteraciones en el ECG, entre las que las más frecuentes son repolarizaciones precoces, incremento del voltaje del QRS, inversiones más o menos difusas de las ondas T y Q profundas, así como alteraciones de la conducción cardíaca (bradicardias, bloqueos AV tipo Wenkeback y ritmos nodales), así como arritmias ventriculares (extrasístoles e incluso salvas de taquicardia ventricular). Estas alteraciones pueden simular y dificulatar el diagnóstico de determinadas enfermedades cardíacas como las cardiomiopatias hipertrófica, dilatada o la cardioimiopatía ventricular derecha arritmogénica, que es la principal causa de muerte súbita en personas jóvenes.
De los resultados de este estudio se desprende que los deportistas que presentan alteraciones de la repolarización importantes (aproximadamente un 1%) tienen un mayor riesgo de presentar una cardiomiopatía que los que tienen un ECG normal, incluso aunque en la valoración inicial el resto de las exploraciones sean normales (valor predictivo positivo 6%). Estas cardiomiopatías pueden incluso poner en riesgo la vida de la persona (2 sufrieron cuadros de paro cardiorrespiratorio), por lo que parece prudente la recomendación de los autores de hacer un seguimiento clínico.

Bibliografía

  1. Corrado D, Basso C, Pavei A, Michieli P, Schiavon M, Thiene GTrends in Sudden Cardiovascular Death in Young Competitive Athletes After Implementation of a Preparticipation Screening Program. JAMA 2006; 296: 1593-1601.    TC   PDF  RC
  2. Maron BJ, Pelliccia AThe Heart of Trained Athletes: Cardiac Remodeling and the Risks of Sports, Including Sudden Death. Circulation 2006; 114: 1633-1644.   TC (s)   PDF (s)
  3. Pelliccia A, Maron BJ, Culasso F, et alClinical significance of abnormal electrocardiographic patterns in trained athletes. Circulation 2000; 102: 278-284.    TC  PDF

Autor

Manuel Iglesias Rodal. Correo electrónico: mrodal@menta.net.

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More abut Tamiflu


Cochrane CollaborationImage via Wikipedia

By Michael Smith, North American Correspondent, MedPage Today
Published: January 17, 2012
Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco.
A new review of the influenza drug oseltamivir (Tamiflu) has raised questions about both the efficacy of the medication and the commitment of its maker to supply enough data for claims about the drug to be evaluated by independent experts.

It also raises questions about the entire process of systematic review.

Researchers led by Tom Jefferson, MD, of the Cochrane Collaboration, pored over 15 published studies and nearly 30,000 pages of “clinical study reports.”

But, they reported, the clinical study information – data previously shared only with regulators – was only a part of what internal evidence suggested was available.

And many published studies had to be excluded because of missing or contradictory data, Jefferson and colleagues reported.

Activate MedPage Today’s CME feature and receive free CME credit on medical stories like this one
Action Points  


  • Explain that a new review of an important flu drug has raised questions about the medication and the entire process of systematic review.
  • Point out that the review of oseltamivir showed that there was no evidence of effect on hospital admissions.
The drug’s maker, Switzerland-based Roche, had promised after a previous Cochrane review to make all of its data available for “legitimate analyses.” After a request for the data, Jefferson and colleagues reported, the company sent them 3,195 pages covering 10 treatment trials of the drug.
But, three of the reviewers noted in a parallel report in BMJ, the tables of contents suggested that the data were incomplete.
“What we’re seeing is largely Chapter One and Chapter Two of reports that usually have four or five chapters,” according to theBMJ article’s lead author, Peter Doshi, PhD, of Johns Hopkins University.
Roche did not immediately respond to a telephoned request for comment.
Requests for More Data
The researchers then asked the European Medicines Agency (EMA) for the data, under a Freedom of Information request, and obtained a further 25,453 pages, covering 19 trials.
But that data, too, was incomplete, they said, although the agency said it was all that was available.
The FDA is thought to have the complete reports, but has not yet responded to requests for them, the researchers reported.
Regulatory agencies such as the EMA and FDA routinely see the large clinical study reports, Jefferson and colleagues said in BMJ, but systematic reviewers and the general medical public do not.
“While regulators and systematic reviewers may assess the same clinical trials, the data they look at differs substantially,” they said.
The Cochrane group has been trying for several years to put together a clear-cut systematic review of the evidence on antivirals aimed at flu.
In 2006, the group concluded that the evidence showed that oseltamivir reduced the complications of the flu. But that conclusion was challenged on the basis that a key piece of data was flawed.
An updated review in 2009 – throwing out the flawed study — concluded there wasn’t enough evidence to show that the drug had any effect on complications.
For this analysis, the Cochrane reviewers had originally intended to perform a systematic review on both of the approved neuraminidase inhibitors – oseltamivir and zanamivir (Relenza), using the clinical study reports to supplement published trials.
In the end, they decided that for oseltamivir, they needed more detail in order to perform the review in its entirety. But, they reported, some conclusions could be drawn from published data on the 15 trials and from 16,000 pages of clinical study reports that were available before their deadline.
They also decided to postpone analysis of zanamivir (for which they had 10 trials) because the drug’s maker, GlaxoSmithKline, offered individual patient data which they wanted time to analyze.
The oseltamivir analysis showed:
  • The time to first alleviation of symptoms in people with influenza-like illness was a median of 160 hours in the placebo groups and about 21 hours shorter in those treated with oseltamivir. The difference, evaluated in five studies, was significant at P<0.001.
  • There was no evidence of effect on hospital admissions: In seven studies, the odds ratio was 0.95, with a 95% confidence interval from 0.57 to 1.61, which was nonsignificant atP=0.86.
  • A post-protocol analysis of eight studies showed that oseltamivir patients were less likely to be diagnosed with influenza.
  • The data “lacked sufficient detail to credibly assess” any effect on influenza complications and viral transmission.
Data Discrepancies Found
But discrepancies between the published trial data and the clinical study reports “led us to lose confidence in the journal reports,” Doshi and colleagues wrote in BMJ.
For example, they noted that one journal report clearly said there were no drug-related serious adverse events, but the clinical study report listed three that were possibly related to oseltamivir.
As well, the sheer scope of the clinical study reports meant that much was left out of journal reports. One 2010 study, on safety and pharmacokinetics of oseltamivir at standard and high dosages, took up seven journal pages and 8,545 pages of the clinical study report.
But the researchers were also shaken, they said, by the “fragility” of some of their assumptions.
For instance, they found that the clinical study reports showed that in many trials, the placebo contained two chemicals not found in the oseltamivir capsules.
“We could find no explanation for why these ingredients were only in the placebo,” they wrote in BMJ, “and Roche did not answer our request for more information on the placebo content.”
Jefferson and colleagues also reported they found disparities in the numbers of influenza-infected people reported to be present in the treatment versus control groups of oseltamivir trials.
One possible explanation, they noted, is that oseltamivir affects antibody production – even though the manufacturer says it does not.
Gaps in Knowledge Remain
That question is profoundly important, Doshi told MedPage Today, because it may offer clues to how the drug works – one of the gaps in knowledge about oseltamivir.
“You can’t make good therapeutic decisions if you don’t know how the drugs works,” he said – information that he and his colleagues suspect may be buried in the mass of missing data.
It’s also important, he said, because public health agencies have been making decisions to stockpile oseltamivir without a clear understanding of the facts.
Essentially, he said, those decisions have been based on the flawed study – a Roche-supported meta-analysis – that was thrown out of the 2009 Cochrane review.
“They’re taking the drug manufacturer’s word at face value,” he said.
The results seem unlikely to resolve conflicts over the medical value of the drug, which is a major cash cow for Roche, adding some $3.4 billion to the company’s bottom line in 2009 alone, according to Deborah Cohen, investigations editor of BMJ.
In an accompanying article, Cohen said that “clinicians can be forgiven for being confused about what the evidence on oseltamivir says.”
She noted that the European Centre for Disease Prevention and Control, the CDC, and the World Health Organization “differ in their conclusions about what the drug does.”
As well, those conclusions are often contradicted by claims on the drug labels – themselves allowed by regulators, Cohen argued.
The Cochrane reviewers reported grant support from the U.K. National Institute for Health Research and Jefferson and Doshi reported they had no recent financial links with industry.
Cohen is employed by BMJ.

Missing clinical trial data


English: Editorial cartoon from the "New ...                                         Image via Wikipedia

BMJ 2012; 344 doi: 10.1136/bmj.d8158 (Published 3 January 2012)

Cite this as: BMJ 2012;344:d8158

      1. Richard Lehman, senior research fellow1
      2. Elizabeth Loder, clinical epidemiology editor2
      Author Affiliations
      1. eloder@bmj.com
      A threat to the integrity of evidence based medicine
      Clinical medicine involves making decisions under uncertainty. Clinical research aims to reduce this uncertainty, usually by performing experiments on groups of people who consent to run the risks of such trials in the belief that the resulting knowledge will benefit others. Most clinicians assume that the complex regulatory systems that govern human research ensure that this knowledge is relevant, reliable, and properly disseminated. It generally comes as a shock to clinicians, and certainly to the public, to learn that this is far from the case.
      The linked cluster of papers on unpublished evidence should reinforce this sense of shock. These articles confirm the fact that a large proportion of evidence from human trials is unreported, and much of what is reported is done so inadequately. We are not dealing here with trial design, hidden bias, or problems of data analysis—we are talking simply about the absence of the data. And this is no academic matter, because missing data about harm in trials can harm patients, and incomplete data about benefit can lead to futile costs to health systems. Moreover, researchers or others who deliberately conceal trial results have breached their ethical duty to trial participants.
      The linked articles look closely at the extent, causes, and consequences of unpublished evidence from clinical trials. Hart and colleagues incorporated unpublished evidence into existing meta-analyses of nine drugs approved by the US Food and Drug Administration in 2001 and 2002.1 These reanalyses produced identical estimates of drug efficacy in just three of 41 cases (7%); in the remaining cases, estimates of drug efficacy were evenly split between more (19/41) and less (19/41). It is sometimes assumed that incorporation of missing data will reduce estimates of drug benefits, but this study shows that “publication bias” can cut both ways. Each increment of data can change the overall picture, but in most cases with no certainty that the picture is complete.
      A fundamental step towards tackling this problem was taken in 2005, when, as Chan describes in the Research Methods and Reporting section, prior registration of all trials became a condition for later publication.2 Chan details the ways in which authors of systematic reviews can search for unpublished evidence, and he strikes an optimistic note when he states that “Key stakeholders—including medical journal editors, legislators, and funding agencies—provide enforcement mechanisms that have greatly improved adherence to registration practices.”
      However, two studies we publish give little cause for optimism that this adherence extends to timely sharing of trial results. A survey of publicly funded research in the United States between 2005 and 2008 by Ross and colleagues shows that registration is not followed by reporting of summary results within 30 months of completion in more than half of trials.3 Even at three years, one third remain unpublished. The US Food and Drug Administration Amendments Act of 2007 made publication of a results summary on ClinicalTrials.gov within 12 months mandatory for all eligible trials in the US “initiated or ongoing as of September 2007”—Prayle and colleagues examine the extent to which this has happened.4 The tally stands at 22%. When the word “mandatory” turns out to mandate so little, the need for stronger mechanisms of enforcement becomes very clear.
      Most clinical interventions in current use, however, are based on trials carried out before the era of mandatory registration, and here the task of data retrieval by systematic reviewers and national advisory bodies becomes impossible. Wieseler and colleagues show that the different documents available to researchers and regulators—internally produced study reports, study findings published in peer reviewed journals, and results posted in results registries—supplement each other, but that reporting quality is highest in study reports. However, the effort required to find and collate these sources can be prodigious and seldom guarantees completeness.5 In their just published Cochrane review update on antiviral treatments for influenza, Jefferson and colleagues describe a painstaking search for information from undisclosed trials stretching over several years.6
      There is an “Alice in Wonderland” feel to these investigators’ efforts—acting on the public’s behalf, searching over hill and dale and among the paperwork of regulatory bodies and drug companies to put together pieces of data that should have been freely available in the first place. Even when data on individual participants are made available, they only form part of the jigsaw, and Ahmed and colleagues describe the problems of fitting in such data when the whole picture is not known.7
      Finally, to find the randomised clinical trials that have been published in the medical literature, nearly every student, clinician, or researcher turns first to Medline among the biomedical databases. But Wieland and colleagues find that many reports of randomised controlled trials entered into Medline between 2006 and 2011 have not been indexed as such; thus, simply entering the search term “randomised controlled trial” into this database will miss many of these trials, despite the best efforts of the Cochrane Collaboration and the US National Library of Medicine.8
      What is clear from the linked studies is that past failures to ensure proper regulation and registration of clinical trials, and a current culture of haphazard publication and incomplete data disclosure, make the proper analysis of the harms and benefits of common interventions almost impossible for systematic reviewers. Our patients will have to live with the consequences of these failures for many years to come. Retrospective disclosure of full individual participant data would be an important first step towards better understanding of the benefits and harms of many kinds of treatment. A model for this is provided by Medtronic’s recent agreement to release full individual participant data relating to its controversial bone product—recombinant human bone morphogenetic protein-2—to independent analysis teams; so there is no longer any convincing reason for other companies to refuse similar disclosure of de-identified participant data from all past trials.9
      The main challenge is to ensure better systems for the future. Because “the optimal systematic review would have complete information about every trial—the full protocol, final study report, raw dataset, and any journal publications and regulatory submissions,”2 10 a prospective system of research governance should insist on nothing less. This may require the global organisation of a suitable shared database for all raw data from human trials—an obvious next step for the World Health Organization after its excellent work on the International Clinical Trials Registry Platform Search Portal. Concealment of data should be regarded as the serious ethical breach that it is, and clinical researchers who fail to disclose data should be subject to disciplinary action by professional organisations. This may achieve quicker results than legislation in individual countries, although this is also desirable.
      These changes have been long called for,11 and delay has already caused harm. The evidence we publish shows that the current situation is a disservice to research participants, patients, health systems, and the whole endeavour of clinical medicine.

      Notes

      Cite this as: BMJ 2012;344:d8158

      Footnotes

      References

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      Contraceptive pill associated with increased prostate cancer risk worldwide


      Age-standardised death rates from Prostate can...Image via Wikipedia

      ABSTRACT
      Background: Several recent studies have suggested that oestrogen exposure may increase the risk of prostate cancer (PCa).
      Objectives: To examine associations between PCa incidence and mortality and population-based use of oral contraceptives (OCs). It was hypothesised that OC by-products may cause environmental contamination, leading to an increased low level oestrogen exposure and therefore higher PCa incidence and mortality.
      Methods: The hypothesis was tested in an ecological study. Data from the International Agency for Research on Cancer were used to retrieve age-standardised rates of prostate cancer in 2007, and data from the United Nations World Contraceptive Use 2007 report were used to retrieve data on contraceptive use. A Pearson correlation and multivariable linear regression were used to associate the percentage of women using OCs,intrauterine devices, condoms or vaginal barriers to the age standardised prostate cancer incidence and mortality. These analyses were performed by individual nations and by continents worldwide.
      Results: OC use was significantly associated with prostate cancer incidence and mortality in the individual nations worldwide (r¼0.61 and r¼0.53, respectively; p<0.05 for all). PCa incidence was also associated with OC use in Europe (r¼0.545, p<0.05) and by continent (r¼0.522, p<0.05). All other forms of contraceptives (ie, intra-uterine devices, condoms or vaginal barriers) were not correlated with prostate cancer incidence or mortality. On multivariable analysis the correlation with OC was independent of a nation’s wealth. Conclusion: A significant association between OCs and PCa has been shown. It is hypothesised that the OC effect may be mediated through environmental oestrogen levels; this novel concept is worth further ……. Risk Factor Oral Contraceptive Prostate Cancerhttp://www.scribd.com/embeds/72841348/content?start_page=1&view_mode=list&access_key=key-2l5oid9gttp9s328jdpz(function() { var scribd = document.createElement(“script”); scribd.type = “text/javascript”; scribd.async = true; scribd.src = “http://www.scribd.com/javascripts/embed_code/inject.js&#8221;; var s = document.getElementsByTagName(“script”)[0]; s.parentNode.insertBefore(scribd, s); })();

      David Pencheon: Good general practice is sustainable general practice and vice versa


      Source: BMJ blogs

      2 Nov, 11 | by BMJ Group
      David Pencheon
      Once again the RCGP’s Annual conference last week in Liverpool produced a wealth of stimulating and topical debates – from the ethics of whether doctors should take a lead in commissioning (why do we always feel the need to “take the lead?”), to what constitutes sustainable general practice. The groups considering the latter issue, chaired by Tim Ballard and Trevor Thompson, concluded that when done well general practice and primary care is, by its very nature, sustainable: keeping people healthy, independent, empowered, and out of hospital. However, these worthy aspirations don’t always inspire and direct individuals to more specific action. Of course, there is the usual list of ways in which we can do the day job in a more environmentally sensitive way: declutter, go even more paperless, measure and reduce energy consumption, more teleconsultations (did I hear correctly that one Cornish practice has exceeded 50% here?), better procurement, fewer and more integrated collection of specimens, visits on foot, by bike, on a (electric) scooter.
      However, the group felt that if we really wanted to be truly sustainable, there should be a focus on the models of care for its population that really would keep people healthy, independent, empowered, and out of hospital. What was needed, the group felt, was a specific list of clinical and health related areas where significant action (or research if necessary) should be commissioned and/or implemented. What are the known knowns (or even the known unknowns) where systematic and exemplary action would have the most effect to immediate and long term patient care and population health? 
      Five areas emerged, neatly summarised by Peter Cawston, a GP from Glasgow:
      1. Helping people eat better and move better (where some of the most significant co-benefits for health can be made. Over eating red processed meat is not good for immediate health or for longer term environmental survival and the use of fossil fuel to travel is good neither for our own health nor our children’s – as well as being dangerously carbon intensive).
      2. Enabling women to have control over their fertility (especially pertinent as we welcome the 7 billionth citizen to the planet).
      3. Targeting prescribing on those most likely to benefit (in particular moving from target driven medication lists to therapy tailored to the individual, with consequent improvements in safety and effectiveness as well as reductions in financial and environmental costs arising from the manufacture and use of drugs).
      4. Promoting a greater sense of belonging (helping people to connect more and consume less, building on the personal trusting relationships at the core of general practice).
      5. Helping people manage a better death (where the avoidance of death and promotion of longevity as signs of success need to be recalibrated to what is a much more humane and dignified approach to helping people manage their end of life, and end of life care).
      David Pencheon is a UK trained public health doctor and is currently director of the NHS Sustainable Development Unit (England).

      British breast cancer screening now under independent review


      Normal (left) versus cancerous (right) mammogr...Image via Wikipedia

      Source: Health News Review

       No Comments  No TrackBacks
      Questions about how best to communicate to the public about the tradeoffs of potential benefits versus potential harms of mammography do not end at America‘s shores.

      An independent investigation into breast cancer screening has been set up by the government’s cancer chief to try to settle the growing controversy around its usefulness and potential harms.

      Prof Sir Mike Richards‘s move is an attempt to put to rest the criticisms of a number of scientists, who say the NHS (British National Health Service) screening programme wrongly identifies cancers that might never harm women, leading to unnecessary and potentially damaging treatment with surgery, drugs and radiation therapy.
      They also contest the official NHS position, which is that although there is some over-treatment as a result of screening, mammograms save lives.
      The BMJ today published a letter from Susan Bewley, professor of complex obstetrics, Division of Women’s Health, King’s College London, to the man BMJ calls “England’s cancer tsar,” Mike Richards. Excerpt of her letter: 

      “I declined screening when it was offered, as the NHS breast screening programme was not telling the whole truth. As a non-expert in the subject, I found myself examining the evidence for breast screening with increasing doubts. I compared the NHS and Nordic Cochrane Centre leaflets and found that the NHS leaflets exaggerated benefits and did not spell out the risks. Journals showed a reputable and growing body of international opinion acknowledging that breast cancer screening was not as good as used to be thought. The distress of overdiagnosis and decision making when finding lesions that might (or might not) be cancer that might (or might not) require mutilating surgery is increasingly being exposed. The oft repeated statement that “1400 lives a year are saved” has not been subjected to proper scrutiny. Even cancer charities use lower estimates. I expressed my misgivings to you “behind the scenes” as a work colleague. You replied in a personal email “that the large majority of experts in this country disagrees with the methodology used in the Cochrane Centre reviews of breast screening.”

      It is extraordinary to be told that methodology is contentious so many years into the national programme.”

      “I take the current controversy very seriously. I will do my best to achieve consensus on the evidence, though I realise this may not ultimately be possible. Should the independent review conclude that the balance of harms outweighs the benefits of breast screening, I will have no hesitation in referring the findings to the UK National Screening Committee and then ministers. You also have my assurance that I am fully committed to the public being given information in a format that they find acceptable and understandable and that enables them to make truly informed choices.”

      Estimating treatment effects for individual patients based on the results of randomised clinical trials


      BMJ 2011; 343:d5888 doi: 10.1136/bmj.d5888 (Published 3 October 2011)

      Cite this as: BMJ 2011; 343:d5888

      • Research

      Estimating treatment effects for individual patients based on the results of randomised clinical trials

      Free via Creative Commons: OPEN ACCESS

      1. Johannes A N Dorresteijn, epidemiologist and medical doctor1,
      2. Frank L J Visseren, professor of vascular medicine, epidemiologist, and internist1
      3. Paul M Ridker, Eugene Braunwald professor of medicine, epidemiologist, and cardiologist2
      4. Annemarie M J Wassink, internist and postdoctoral researcher1
      5. Nina P Paynter, assistant professor of epidemiology2
      6. Ewout W Steyerberg, professor of medical decision making, and methodologist3
      7. Yolanda van der Graaf, professor of epidemiology and imaging4
      8. Nancy R Cook, associate professor of biostatistics and epidemiology2
      Author Affiliations

      1. 1Department of Vascular Medicine, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, Netherlands


      2. 2Division of Preventive Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA


      3. 3Department of Public Health, Erasmus Medical Center, Rotterdam, Netherlands


      4. 4Julius Center for Health Sciences and Primary Care, Utrecht, Netherlands

      1. Correspondence to: F L J Visseren F.L.J.Visseren@umcutrecht.nl
      • Accepted 12 August 2011

      Abstract

      Objectives To predict treatment effects for individual patients based on data from randomised trials, taking rosuvastatin treatment in the primary prevention of cardiovascular disease as an example, and to evaluate the net benefit of making treatment decisions for individual patients based on a predicted absolute treatment effect.
      Setting As an example, data were used from the Justification for the Use of Statins in Prevention (JUPITER) trial, a randomised controlled trial evaluating the effect of rosuvastatin 20 mg daily versus placebo on the occurrence of cardiovascular events (myocardial infarction, stroke, arterial revascularisation, admission to hospital for unstable angina, or death from cardiovascular causes).
      Population 17 802 healthy men and women who had low density lipoprotein cholesterol levels of less than 3.4 mmol/L and high sensitivity C reactive protein levels of 2.0 mg/L or more.
      Methods Data from the Justification for the Use of Statins in Prevention trial were used to predict rosuvastatin treatment effect for individual patients based on existing risk scores (Framingham and Reynolds) and on a newly developed prediction model. We compared the net benefit of prediction based rosuvastatin treatment (selective treatment of patients whose predicted treatment effect exceeds a decision threshold) with the net benefit of treating either everyone or no one.
      Results The median predicted 10 year absolute risk reduction for cardiovascular events was 4.4% (interquartile range 2.6-7.0%) based on the Framingham risk score, 4.2% (2.5-7.1%) based on the Reynolds score, and 3.9% (2.5-6.1%) based on the newly developed model (optimal fit model). Prediction based treatment was associated with more net benefit than treating everyone or no one, provided that the decision threshold was between 2% and 7%, and thus that the number willing to treat (NWT) to prevent one cardiovascular event over 10 years was between 15 and 50.
      Conclusions Data from randomised trials can be used to predict treatment effect in terms of absolute risk reduction for individual patients, based on a newly developed model or, if available, existing risk scores. The value of such prediction of treatment effect for medical decision making is conditional on the NWT to prevent one outcome event.
      Trial registration number Clinicaltrials.gov NCT00239681.

      Tiago Villanueva: quaternary prevention


      Tiago Villanueva: quaternary prevention

      Tiago_VillanuevaThe primary care innovation seminars group, a primary healthcare think tank that was created in Spain in 2005, convened this weekend in Barcelona. The group used to meet several times a year in Madrid. This year, group members gathered for the first time outside the Spanish capital, with the added bonus of the presence of many leading GPs from around the world, who were in Barcelona for the annual meeting of the World Organization of Family Doctors International Classification Committee (WICC). Many of the WICC members were speakers at the seminar, including Juan Gérvas, a Spanish GP and leader of the primary care innovation seminars group.
      Domhnall Macauley and I have previously mentioned the concept of quaternary prevention, but few can describe it like Marc Jamoulle, a Belgian GP and one of the world’s leading experts in quaternary prevention, who says it is all about “the action taken to identify the patient at risk of overmedicalisation, to protect him from new medical interventions, and to suggest other interventions to him, which are ethically acceptable.”
      The concept of quaternary prevention has been gaining momentum among the primary health care academic community over the last few years, but it has been known for decades. Sometimes, the best approach to a health problem is acknowledging when to avoid providing unnecessary healthcare. For example, one participant in the seminar said that for the last 30 years a military hospital in the United States has considered it acceptable not to treat burns patients with burns in over 95% of their body surface due to the poor prognosis of such patients.
      Gustavo Gusso, president of the Brazilian Society of Family Medicine, said that in order to successfully teach quaternary prevention, we need to produce relevant scientific information, including protocols that start with the symptom rather than with the disease. He pointed out that even though diagnosis and disease centered protocols have many limitations, we were failing to do better.
      Juan Gérvas added that, even though many patients these days have multiple health problems, conferences about single health problems and diseases remain the norm (for example, diabetes), while conferences about multimorbidity remain rare. So he called for participation in a meeting in 2012 organised by the Spanish Primary Care Network about schizophrenic diabetic patients, and wondered if anyone was aware of guidelines for diabetic patients with schizophrenia. No one responded.
      One of the key ideas Gérvas conveyed was that it is pivotal to keep patients away from the health system when they don’t need healthcare at all, as well as being extremely cautious about the dangers of expanding access to health services. For example, introducing radiology services in primary health care may cause unnecessary harm if used excessively.
      He also mentioned the example of the King of Spain, Don Juan Carlos, who goes to Barcelona every year to have a “check-up,” encouraging many Spanish people to do the same and therefore to potentially damage their health. In the case of the King, he said that a pulmonary nodule was found last year that was most likely benign, but which still triggered potentially avoidable surgery that subsequentely prevented the King from attending the football World Cup in South Africa. Vicente Ortún, dean of the Faculty of Economics of the Pompeu Fabra University, in Barcelona, emphasised that quaternary prevention increases both effectiveness and equity.
      Leading Spanish health economist Beatriz López-Valcarcel, from the University of Las Palmas, in the Canary Islands, explained that even though assisted reproduction was successful only in about 7% of Australian women aged between 40 and 44 years, the Australian Government still decided to keep funding it. It may not make sense to clinicians to fund potentially useless medical interventions, but she stressed the idea that the goal of the health system was not to save, but rather to attain a balance between health benefits and risks, and between effectiveness and costs. So keep this in mind the next time you hear about politicians making decisions about the health system that don’t seem to make any sense.
      Tiago Villanueva is a GP based in Portugal and a former BMJ clegg scholar and editor, Student BMJ. He personally paid for all the travel expenses to attend the seminar in Barcelona.

      Knowledge patient


      Quién define la enfermedad ?


      BMJImage via Wikipedia
      Es el título de un excelente editorial del BMJ. Un tema de por si polémico, ya que basta con preguntar a dos médicos que significa la salud, y contestarán cosas diferentes, o bien el versito aprendido de la OMS. Definir la enfermedad es aceptar su existencia, luego de años de aprendizaje o des-aprendizaje, donde nos enseñaron que no había enfermedades sino enfermos. Para la mayoría de los médicos distinguir entre un factor de riesgo y una enfermedad ya constituye todo un desafío.
      No son pocos los que cómo Foucault señaló en su libro “El nacimiento de la clínica”, la salud es el silencio de los órganos, y para la mayoría de mis profesores universitarios, una persona sana es un paciente que no ha sido estudiado exhaustivamente. Abonando de esta manera a una sociedad altamente medicalizada como la que tenemos.
      El mandato judeo-cristiano de nominar las cosas para que ellas existan, se dá en los adeptos a las taxonomías. Aunque basta leer el DSM-IV para encontrarse reflejado en no menos de 10 categorías.  Un tema que no resulta menor, ya que en la mayoría, sino en todas, a cada entidad le corresponde un medicamento.
      Enfermedades imaginarias conviven hoy con enfermedades olvidadas (como el mal de Chagas-Mazza o tripanosomiasis americana, que en Argentina se estima en al menos 3 millones de personas infectadas). Los propios griegos clasificaron las enfermedades entre aquellas que se podían curar y las que no.
      Ruiz Perez Tamayo, nos remite a otra clasificación como la de las enfermedades históricas (tal cómo el cáncer que es reconocido desde siglos atrás), las transitorias (donde incluye a un par de problemas de salud que se dieron en la edad media, donde la gente salía a bailar y pasaba días haciéndolo hasta morir por agotamiento (Mal de San Vitto), y que la ciencia de entonces no supo explicar. También enfermedades llamadas emergentes, particularmente infecciosas, que se creían derrotadas o a punto de transformarse en otro éxito médico como fue la erradicación de la viruela.
      La lista pudiera ser más extensa, lo cierto es que no pocos problemas tienen dificultades en ser tratados como enfermedades, factores de riesgo, o incluso delitos o pecados. Del mismo modo que hay enfermedades que NO existen, como el Síndrome de la Guerra del Golfo, que no es reconocido por las propias autoridades estadounidenses (del mismo modo que alguna vea ignoraron al SIDA por ser un problema de pecadores), y se lo considera como stress postraumático.
      Sin duda éste tema merece un tratamiento más extenso, pero su abordaje es una deuda pendiente. Años atrás un especialista en medicina interna de Argentina, decía en un periódico que el 90% de la gente que consultaba no tenia nada, supongo que se refería a nada orgánico, ignorando de este modo el abordaje integral e integrado que la visión de nuestra especialidad tiene, o al menos debiera tener.
      Quienes tratamos con personas en el primer nivel de atención, sabemos de la incertidumbre, de problemas de salud incipientes que no podemos “nominar”, y quizás no lo debieramos hacer, salvo para llevar alguna estadística, pero ese es un problema nuestro, no de la gente, quienes, al igual que nosotros, por más que la medicina progrese, no estaremos nunca exentos de enfermar y morir. Dos características básicas de nuestra esencia como húmanos. Va el artículo.

      Quien Define La Enfermedad BMJ,2011[1]http://es.scribd.com/embeds/65737379/content?start_page=1&view_mode=list&access_key=key-1k2s713zt2vm9x2p12tv(function() { var scribd = document.createElement(“script”); scribd.type = “text/javascript”; scribd.async = true; scribd.src = “http://es.scribd.com/javascripts/embed_code/inject.js&#8221;; var s = document.getElementsByTagName(“script”)[0]; s.parentNode.insertBefore(scribd, s); })();

      A cure for the disease of hate


      BMJImage via Wikipedia

      BMJ 2011; 343:d5715 doi: 10.1136/bmj.d5715 (Published 14 September 2011)

      Cite this as: BMJ 2011; 343:d5715
      • Views & Reviews
      • Review of the Week

      A cure for the disease of hate

      1. Iain McClure, consultant child and adolescent psychiatrist, Royal Hospital for Sick Children, Edinburgh
      1. imcclure@nhs.net
      A Gazan doctor working in Israel describes his life and extraordinary tragedy, with a determination that good must come from bad. Iain McClure recommends his book to all doctors
      On 16 January 2009 three Palestinian sisters were killed when an Israeli tank fired two shells into their bedroom. They were the daughters of Dr Izzeldin Abuelaish, a Palestinian gynaecologist, who, uniquely for a Gazan doctor, held a consultant post in an Israeli hospital. Abuelaish’s book, I Shall Not Hate, is an account of his life up to this momentous event and movingly explains his remarkable reaction. In essence, Abuelaish, who likens hate to disease and communication to cure, has drawn on his medical experience to seek a new approach to the resolution of apparently insoluble conflict.
      For the three weeks prior to January 2009 the Israeli Defense Forces had been pursuing an incursion into the Gaza Strip to eradicate Quassam rocket attacks into Israel. The Israeli government had prevented Israeli or foreign journalists broadcasting from within Gaza during the operation. However, Abuelaish, a well known public figure in Gaza, had …

      Eficacia comparativa de los tratamientos para la ansiedad generalizada



      Baldwin D, Woods R, Lawson R, Taylor DEfficacy of drug treatments for generalised anxiety disorder: systematic review and meta-analysis. BMJ 2011; 342: d1199-.    TC   PDF

      Introducción

      A pesar de que la ansiedad es un problema muy frecuente, las revisiones sobre la eficacia de los tratamientos disponibles comparan la eficacia de tratamientos del mismo grupo y no los de los diferentes grupos de psicofármacos entre sí.

      Objetivo

      Comparar la eficacia y la tolerancia de todos los tratamientos disponibles para el trastorno de ansiedad generalizada a partir de los ensayos clínicos publicados sobre el tema.

      Perfil del estudio

      Tipo de estudio: Metaanálisis
      Área del estudio: Tratamiento
      Ámbito del estudio: Comunitario

      Métodos

      Se llevó a cabo una búsqueda en las principales bases de datos bibliográficas para localizar los estudios llevados a cabo sobre la ansiedad generalizada de los siguientes tipos:

      • ensayos clínicos doble ciego controlados con placebo de fase II,III y IV de cualquier duración, 
      • los ensayos clínicos controlados llevados a cabo en ≥18 años con cualquier tratamiento y
      • revisiones sistemáticas y metaanálisis de los anteriores.

      Las variables de resultado principal para valorar la eficacia fueron las tasas de remisión (puntuación final en la escala de Hamilton ≤7) y de respuesta (reducción ≥50% en la puntuación inicial de la escala de Hamilton) y para valorar la tolerancia, las tasas de abandono.
      Se llevó a cabo un análisis probabilísitico mediante modelos bayesianos que permitieron clasificar los diferentes tratamientos en función de la probabilidad de que fuesen los más eficaces para cada uno de los resultados.

      Resultados

      Se incluyeron en el análisis los datos de 27 estudios (fig. 1) que contenían información sobre 9 fármacos: duloxetina, escitalopram, fluoxetina, lorazepam, paroxetina, pregabalina, sertralina, tiagabina y venlafaxina. Casi la totalidad se habían publicado a partir del año 2000.

      Figura 1Proceso de selección de los estudios.

      La tabla 1 muestra las comparaciones de las que se dispuso para hacer el análisis.

      Tabla 1. Número de estudios de los que se dispuso datos para cada una de las comparaciones.

      Venlafaxina Escitalopram Pregabalina Paroxetina Duloxetina Sertralina Lorazepam Tiagabina Fluoxetina
      Placebo 8 4 5 3 5 2 3 2 1
      Venlafaxina   1 2 1
      Escitalopram     2
      Pregabalina       2
      Paroxetina         1
      Duloxetina          
      Setralina            
      Lorazepam              
      Tiagabina                
      Total 8 5 5 5 5 3 2 2 1

      Casi todos los tratamientos mostraron una tasa de respuesta y de remisión superior al placebo (odds ratio<1) que alcanzó la significacion estadística, pero en  las comparaciones directas entre ellos las diferencias fueron pequeñas (tablas 2 y 3). Las tasas de abandono también fueron superiores para casi todos los tratamientos que para el placebo, pero con pocas diferencias entre los tratamientos (tabla 4).

      Tabla 2Odds ratio de responder al tratamiento en la comparación entre los diferentes fármacos entre sí y con el placebo. (Si la odds ratio es <1, es favorable al fármaco del encabezamiento de la columna).

      Venlafaxina Escitalopram Pregabalina Paroxetina Duloxetina Sertralina Lorazepam Tiagabina Fluoxetina
      Placebo 0,53
      (0,45 a 0,61)
      0,67
      (0,39 a 1,14)
      >0,52
      (0,39 a 0,68)
      0,48
      (0,30 a 0,77)
      0,45
      (0,38 a 0,54)
      0,45
      (0,33 a 0,62)
      0,40
      (0,24 a 0,66)
      0,81
      (0,64 a 1,08)
      0,27
      (0,09 a 0,81)
      Venlafaxina   1,3
      (0,62 a 2,82)
      1,06
      (0,76 a 1,49)
      0,93
      (0,46 a 1,96)
      0,99
      (0,74 a 1,32)
      0,87
      (0,53 a 1,5)
      0,77
      (0,45 a 1,32)
      1,41
      (0,92 a 2,25)
      0,87
      (0,38 a 2,01)
      Escitalopram 0,77
      (0,35 a 1,65)
        0,76
      (0,34 a 1,7)
      0,96
      (0,29 a 1,63)
      0,67
      (0,32 a 1,47)
      0,76
      (0,34 a 1,7)
      0,59
      (0,23 a 1,55)
      1,09
      (0,48 a 2,46)
      0,39
      (0,1 a 1,64)
      Pregabalina 0,94
      (0,67 a 1,32)
      1,3
      (0,59 a 2,9)
        0,94
      (0,44 a 2,02)
      0,89
      (0,6 a 1,32)
      0,88
      (0,49 a 1,58)
      0,78
      (0,49 a 1,24)
      1,42
      (0,84 a 2,4)
      0,74
      (0,29 a 1,86)
      Paroxetina 1,09
      (0,51 a 2,23) 
       0,9
      (0,45 a 1,78)
      1,08
      (0,5 a 2,32)
        0,95
      (0,46 a 1,98)
      0,96
      (0,42 a 2,16)
      0,83
      (0,33 a 2,06)
      1,54
      (0,69 a 3,33)
      0,57
      (0,13 a 2,36)
      Duloxetina 1,01
      (0,76 a 1,35)
      1,45
      (0,68 a 3,18) 
      1,12
      (0,75 a 1,67)
      1,06
      (0,51 a 2,22)
        1,01
      (0,59 a 1,73)
      0,87
      (0,45 a 1,72)
      1,62
      (1,01 a 2,55)
      0,84
      (0,35 a 1,97)

      Tabla 3Odds ratio de presentar una remisión en la comparación entre los diferentes fármacos entre sí y con el placebo. (Si laodds ratio es <1, es favorable al fármaco del encabezamiento de la columna).

      Venlafaxina Escitalopram Paroxetina Duloxetina Sertralina Tiagabina Fluoxetina
      Placebo 0,45 (0,37 to 0,55) 0,34 (0,20 to 0,57) 0,45 (0,33 to 0,63) 0,53 (0,47 to 0,65) 0,78 (0,29 to 0,78) 0,76 (0,57 to 1,01) 0,24 (0,06 to 0,97)
      Venlafaxina   0,77 (0,37 to 1,7) 1,05 (0,62 to 1,9) 1,2 (0,93 to 1,56) 1,1 (0,52 to 2,33) 1,74 (1,07 to 2,95) 0,71 (0,3 to 1,64)
      Escitalopram 1,31 (0,56 to 2,81)   1,38 (0,59 to 3,3) 1,61 (0,73 to 3,5) 1,43 (0,52 to 3,84) 2,21 (0,95 to 5,06) 0,72 (0,15 to 3,78)
      Paroxetina 0,96 (0,52 to 1,64) 0,74 (0,32 to 1,78)   1,18 (0,68 to 2,03) 1,06 (0,46 to 2,42) 1,66 (0,89 to 3,03) 0,49 (0,11 to 2,47)
      Duloxetina 0,62 (0,29 to 1,32) 0,85 (0,5 to 1,46)   0,9 (0,43 to 1,84) 1,42 (0,88 to 2,25) 0,83 (0,64 to 1,08)
      Tabla 4Odds ratio de abandonar al tratamiento en la comparación entre los diferentes fármacos entre sí y con el placebo. (Si la odds ratio es <1, es favorable al fármaco del encabezamiento de la columna).

      Venlafaxina Escitalopram Pregabalina Paroxetina Duloxetina Sertralina Lorazepam Tiagabina Fluoxetina
      Placebo 2,70
      (1,79 to 4,0)
      2,86
      (1,64 to 4,76)
      1,79
      (1,15 to 2,78)
      5,26
      (2,50 to 11,11)
      3,57
      (2,50 to 5,26)
      1,12
      (0,61 to 2,04)
      2,26
      (2,5 to 11,11)
      2,5
      (1,64 to 4,0)
      1,54
      (0,13 to 16,67)
      Venlafaxina   1,07
      (0,47 to 2,34)
      0,63
      (0,38 to 1,04)
      0,94
      (0,41 to 2,05)
      1,24
      (0,84 to 1,83)
      0,43
      (0,17 to 1,05)
      1,47
      (0,71 to 3,07)
      0,99
      (0,46 to 2,11
      0,49
      (0,11 to 2,09)
      Escitalopram 0,98
      (0,41 to 2,22)
        0,66
      (0,27 to 1,52)
      0,94
      (0,36 to 2,29)
      1,32
      (0,56 to 2,97)
      0,44
      (0,15 to 1,22)
      1,91
      (0,61 to 5,58)
      0,97
      (0,38 to 2,37)
      0,62
      (0,04 to 6,47)
      Pregabalina 1,57
      (0,94 to 2,62)
      1,58
      (0,69 to 3,57)
        1,38
      (0,62 to 3,25)
      1,97
      (1,07 to 3,63)
      0,66
      (0,26 to 1,76)
      1,92
      (1,17 to 3,16)
      1,47
      (0,65 to 3,32)
      0,77
      (0,16 to 3,82)
      Paroxetina 1,05
      (0,44 to 2,62)
      0,73
      (0,3 to 1,78)
      0,67
      (0,27 to 1,69)
        1,4
      (0,59 to 3,43)
      0,46
      (0,16 to 1,43)
      2,03
      (0,61 to 6,95)
      1,02
      (0,41 to 2,76)
      0,58
      (0,03 to 8,51)
      Duloxetina 0,81
      (0,55 to 1,19)
      0,78
      (0,36 to 1,74)
      0,5†
      (0,27 to 0,91)
      0,71
      (0,32 to 1,57)
        0,34
      (0,13 to 0,83)
      1,46
      (0,54 to 3,92)
      0,74
      (0,34 to 1,56)
      0,49
      (0,1 to 2,38)

      La tabla 5 muestra los resultados del análisis probabilístico con el orden resultante para cada uno de los resultados. La fluoxetina era la que tenía una mayor probabilidad de quedar primera en el ranking en remisión y respuesta y la sertralina en cuanto a la tolerancia del tratamiento.

      Tabla 5. Posición de cada uno de los tratamientos para cada uno de los resultados analizados.
      Posición Remisión Respuesta Abandono
      1 Fluoxetina Fluoxetina Sertralina
      2 Escitalopram Lorazepam Pregabalina
      3 Venlafaxina Duloxetina Fluoxetina
      4 Paroxetina Sertralina Paroxetina
      5 Sertralina Paroxetina Tiagabina
      6 Duloxetina Pregabalina Venlafaxina
      7 Tiagabina Venlafaxina Escitalopram
      8 ND Escitalopram Duloxetina
      9 ND Tiagabina Lorazepam

      Conclusiones

      Los autores concluyen que el análisis probabilístico sugiere que la fluoxetina en términos de eficacia (respuesta y remisión de los síntomas) y la sertralina (en términos de tolerancia) presentan algunas ventajas sobre los otros fármacos.

      Conflictos de interés

      Varios de los autores han recibido honorarios de la industria farmacéutica por diferentes conceptos. Financiado por Lundbeck.

      Comentario

      El trastorno de ansiedad generalizada es un problema frecuente en atención primaria. Se caracteriza por la presencia de una ansiedad persistente y excesiva, que se acompaña de otros síntomas somáticos (palpitaciones, sudoración, temblor, boca seca) y psicológicos (inquietud, insomnio, cansancio, problemas de concentración, irritabilidad y tensión muscular). Se deben descartar otros cuadros que cursan con ansiedad como hipocondría, trastorno de angustia, trastorno por somatización y el trastorno obsesivo-compulsivo. Afecta en un momento determinado a un 1-2% de la población y un 4-6% de las personas padecerán este problema a lo largo de la vida. Las mujeres tienen el doble de prevalencia que los varones. La mayor parte de los pacientes no consultan al médico por este motivo y de los que consultan menos de la mitad consiguen la remisión del cuadro.
      Se puede tratar tanto mediante autoayuda (manuales, relajación, ejercicio, fitoterapia), técnicas psicológicas (intervención breve, tratamiento cognitivo-conductual, terapias de base dinámica, técnicas de manejo de la ansiedad y tratamientos conductistas) y farmacológicas. Existen pocos estudios sobre la eficacia de las primeras y sobre la eficacia comparativa de ambos abordajes. Entre los tratamientos farmacológicos recomendados se encuentran los ansiolíticos, los antidepresivos y los anticonvulsivantes. También se dispone de pocos estudios que comparen la eficacia de los diferentes fármacos entre sí.
      La técnica metaanalítica utilizada en este estudio permite la comparación entre fármacos utilizando los resultados de estudios que han comparado directamente dos fármacos entre sí o a través de la comparación de ambos con un tercero, que puede ser el placebo. De esta forma, a pesar de que las diferencias entre los fármacos son pequeñas, se puede obtener una gradación de la eficacia relativa de los mismos. El fármaco que presenta mayores tasas de eficacia es la fluoxetina, pero hay que tener en cuenta que esta conclusión se sustenta en un único estudio de pequeño tamaño. De la misma forma, el mejor tolerado resultó la sertralina.

      Bibliografía

      1. Tyrer P, Baldwin DGeneralised anxiety disorder. Lancet 2006; 368: 2156-2166.    TC (s)   PDF (s)
      2. Roy-Byrne P, Veitengruber JP, Bystritsky A, Edlund MJ, Sullivan G, Craske MGBrief Intervention for Anxiety in Primary Care Patients. J Am Board Fam Med 2009; 22: 175-186.    TC   PDF
      3. Kendall T, Cape J, Chan M, Taylor C; On behalf of the Guideline Development GroupManagement of generalised anxiety disorder in adults: summary of NICE guidance. BMJ 2011; 342: c7460   TC   PDF (s)
      4. Furukawa TADrug treatment for generalised anxiety disorder. BMJ 2011; 342: d1216   TC (s)   PDF (s)

      Autor

      Manuel Iglesias Rodal. Correo electrónico: mrodal@menta.net.

      Sobre la necesidad de fomentar la lectura crítica de la información médica


      Gonzalo Casino

      Gonzalo Casino

      La medicina vista desde Internet y pasada por el saludable filtro del escepticismo.


      Infoescepticismo

      Gonzalo Casino
      26 Feb 2010

      El periodismo médico tiende a la exageración. La desmesura está los genes de la información periodística como lo está el impulso de reproducción en el ADN biológico. Hay ya suficientes estudios que muestran que las noticias médicas adolecen de imprecisión, de sesgos, de incompletitud. Las limitaciones de espacio y tiempo, la influencia de la publicidad en el estilo periodístico y esa búsqueda imperiosa e irreflexiva de novedades y avances médicos espectaculares fomentan estas deficiencias. Hay, por supuesto, muchas otras razones, desde la falta de filtros y de conocimientos del periodista a la precarización del oficio de informar, pero no es el momento de ahondar en ellas. Muchos lectores ya saben que todo titular contiene una licencia para exagerar, pero probablemente ignoran otros mecanismos tanto o más importantes que conducen a la distorsión y la desinformación.

      Las noticias médicas se han convertido en el destilado final de un sofisticado engranaje promocional en el que participan investigadores, clínicos, laboratorios, centros de investigación, revistas médicas, asociaciones de pacientes, sociedades científicas y sus intermediarios. El periodismo médico está siendo devorado por esta maquinaria promocional a golpe de comunicados de prensa. Es tan fácil como débil intelectualmente echar la culpa al periodista de las exageraciones, de la falta de rigor y de la banalidad, pero lo cierto es que la comercialización de la información infiltra todo el proceso de la comunicación médica. Richard Smith, el añorado y brillante ex director del BMJ, lo dijo muy claro en el titular de un artículo 2005 en PLoS Medicine:“Las revistas médicas son una extensión de la división de marketing de las compañías famacéuticas”. Un press release (también una rueda de prensa) de un hospital, de una revista médica o de cualquier otro agente ofrece por definición información interesada.
       
      Lo que no saben y debían saber muchos lectores es que casi toda la información de biomedicina está basada en comunicados de prensa. Hay estudios que lo atestiguan, como el de Vladimir de Semir publicado en 1998 en JAMA, o el de Christopher Bartlett publicado en 2002 en BMJ, que mostró que el 100% de las noticias médicas publicadas en dos periódicos británicos tan diferentes como el Times y The Sundurante 1999 y 2000 estaban basadas en press releases. Así las cosas, el tiempo está dando la razón al New England Journal of Medicine, la única entre las principales revistas médicas que no ha elaborado comunicados de prensa semana tras semana para no condicionar la agenda de los periodistas, lo que sin duda le ha restado visibilidad mediática y los supuestos beneficios que lleva emparejados. El periodismo médico ha degenerado de tal modo que muchas de las noticias reproducen hasta los entrecomillados de estos comunicados, y sólo hay algún que otro atisbo de autocrítica entre los periodistas (véase Science Reporting by Press Release, de Cristine Russell, publicado en Columbia Journalism Review).
       
      Si no se remedia, el periodismo médico será engullido por la comunicación. La crisis ha forzado a muchos periodistas a transmutarse en comunicadores o, en casos más aislados, en profesores de periodismo, que ahora están sacando a la luz las deficiencias de una profesión que se repliega cuando quizá sea más necesaria que nunca. Contra lo que se cree, prevenir no siempre es mejor que curar, y este es el caso de las exageraciones en el periodismo médico. Son difíciles de prevenir sencillamente porque hay demasiados intereses en juego. Por eso, es vital que el periodismo médico que todavía queda se concentre en ofrecer herramientas para la lectura crítica de la información. Y es necesario también que los médicos fomenten este escepticismo informativo entre sus pacientes, como aconsejaban dos de los médicos que más están haciendo por reorientar el periodismo, Lisa M. Schwartz y Steven Woloshin, en un editorial de 2003 en el Journal of General Internal Medicine.
       
      ¿Es demasiado buena o demasiado mala esta noticia como para ser cierta? ¿Me afecta esta noticia o se refiere a estudios en ratas? ¿Da cuenta de un trabajo publicado en una revista de prestigio o de un estudio preliminar presentado en un congreso? Este es el tipo de preguntas que todo paciente o lector debiera hacerse. “Las exageraciones están al servicio de muchos intereses”, subrayan Schwartz y Woloshin, “pero no sirven al interés público”. Y en el periodismo, antes que nada, debe prevalecer el interés público. Richard Smith me dijo en una entrevista (El País, 1 de octubre de 2002) que los medios “deberían explicar las dificultades de la información médica y ayudar a la gente a ser consumidores exigentes de noticias”. Esta es la responsabilidad compartida que tienen médicos y periodistas. ¿Y en cuanto a Escepticemia y otros blogs? Léanlos sin piedad y con tanto o más escepticismo.

      Putting research into primary care practice


      BMJ 2011; 343:d3922 doi: 10.1136/bmj.d3922 (Published 5 July 2011)

      Cite this as: BMJ 2011; 343:d3922

      • Editorial

      Putting research into primary care practice

      1. Frede Olesen, professor
      1Research Unit for General Practice, Department of Public Health, Aarhus University, Bartholins Allé 2, DK-8000 Aarhus C, Denmark
      1. fo@alm.au.dk
      The European initiative is a good start, but excludes too many patients and crucial aspects of primary care
      The European Medical Research Council and European Science Foundation recently published a strategic report in its series of “Current Forward Looks” entitled Implementation of Medical Research in Clinical Practice. 1 The collaboration has previously published two strategic reports on the ways forward for basic biological research and for investigator driven clinical trials. 1 By suggesting a strategy on the use of research in practice, it now intends to close the loop. The strategy holds much potential for improving the quality of clinical practice and clinically oriented health services research.
      The report has three main strengths: firstly, it takes strategy and policy to the level of specific recommendations for improving the quality of clinical research; secondly, it presents a strong case for the implementation of good research; and, thirdly, it gives special attention to the particular problems encountered in general practice.
      The report proposes that the quality of clinical research could be improved by closer national and European coordination of independent funding of larger projects, …

      There’ s no free launch


      BMJImage via Wikipedia

      This  is the today’s  editorial of  BMJ, one of  the most  reliable medical  journal  all over the world. The title deals about …..”provision of health information for all”……….but I can’t explain it because I can not read it, because at the end of this abstract says “Full Text of this Article”……..of course, to read the full article I need to pay first. So it doesn’t matter what the editorial says, if you want information, in the information age……….you have to pay….at least for the famous British Medical Journal. Anyway, I think you can read more about this in another blog’s o newspaper like “guardian”, in   related articles.
      BMJ 2011; 342:d4151 doi: 10.1136/bmj.d4151 (Published 30 June 2011)

      Cite this as: BMJ 2011; 342:d4151

      • Editorial

      Provision of health information for all

      1. Richard Smith, director1
      2. Tracey Pérez Koehlmoos, programme head2
      +Author Affiliations
      1. 1UnitedHealth Chronic Disease Initiative, London SW4 0LD, UK
      2. 2Health and Family Planning Systems Programme, ICDDR,B, Dhaka, Bangladesh
      1. richardswsmith@yahoo.co.uk
      A major organisation should support global efforts
      High quality information is essential for good health, yet many individuals, practitioners, and health organisations—particularly in low and middle income countries—lack access to information. This problem has been highlighted many times, 1 2 3 4 and Health Information for All 2015 (HIFA2015) was founded in 2006 with the aim that “by 2015 every person worldwide will have access to an informed healthcare provider—lack of relevant, reliable healthcare information will no longer be a major contributor to avoidable death and suffering” (www.hifa2015.org/ ). It is unlikely that this ambitious goal will be achieved.
      In HIFA2015’s definition, the term “healthcare providers” includes mothers and family caregivers, in recognition that their basic knowledge and decisions are crucial to survival. In many countries in Africa more than 80% of children die before they even reach a health facility. The term “healthcare information” refers to health knowledge for prevention and treatment of disease rather than routine statistical data.
      HIFA2015 now has 5000 members from 2000 organisations in 158 countries, and it has four global forums—HIFA2015, CHILD2015, HIFA-Portuguese, and HIFA-EVIPNet. Most of those who contribute to the forums come from low and middle income countries. The organisation has a three pronged strategy of communication (bringing together a critical …

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      Oseltamivir


      Oseltamivir

      A 7 meses al menos de comenzada la pandemia, una nueva revision clinica de Cochrane parece que re-descubre que las propias revisiones sistematicas realizadas (que de ya de por si eran pobres en efectividad), no sólo demuestran que el oseltamivir no cura, sino que las revisiones realizadas fueron hechas en base a 10 ensayos clínicos donde absolutamente todos, fueron financiados por la propia industria farmaceutica. O para ser más especificos la Farmacéutica Roche. Hace 7 meses que venimos publicando esto, no sólo yo, sino muchos otros que investigamos y publicamos en la web. Hoy el propio British Medical Journal se encuentra con esta “novedad” en su propia editorial. .
      Hemos repetido hasta el cansancio que los unicos ensayos clinicos existentes correspondian a la “gripe vieja”, y que la supuesta resistencia del virus para otros antivirales sólo se habia demostrado in vitro.
      Aún asi, las revisiones sistematicas mostraban una reducción de tan sólo 0,5 a 1 dia de disminucion del tiempo de enfermedad, y de una reducción del 8% en contagios. Claro que todos estos datos surgian de estudios que nadie sabia si eran aplicables o no a este nuevo virus.
      Si pocos protestaron, obras sociales, prepagas, fue porque los gobiernos se hicieron cargo de pagar la medicación. Sin embargo, las consultas y los efectos adversos no reportados, pero que son varios, los pagan los propios “financiadores”. Pero como en paises como Argentina, donde nadie reporta efectos adversos, y por otro lado, no siempre es facil comprobar que el mismo se deba al medicamento, nadie se entera de nada.
      La propia OMS está siendo sospechada desde hace meses, poniendo en juego su credibilidad. Una credibilidad que el propio gobierno polaco y austriaco han hechado por tierra al no aceptar las “recomendaciones” de compra de vacunas. La razón? Muy simple: esos gobiernos no quieren pagar por algo que aseguran que son insuficientes los datos sobre la seguridad de la misma, pero peor aun, se niegan porque las farmaceuticas les imponen 20 cláusulas (la ministra de Salud de Polonia solo se refirio a una, ya que las otras parecen ser secretas), en la cual figura que las farmaceuticas estan exentas de toda responsabilidad, y que los gobiernos son responsables de la misma. Es decir que si la vacuna, genera miles de casos de Guillain Barre, como sucedio con otro N1H1 en EE.UU en 1976, la responsabilidad es de los gobiernos. Lo que deja claramente la pregunta: si la vacuna es tan segura…entonces para que dicha cláusula?
      Porque medicar contra una enfermedad que de por si es autolimitada, no lo haciamos con la gripe común, y a la vista de todos, parece haber menos razones para medicar en una pandemia cuyo protagonista es al menos 4 veces menos letal que su predecesor.
      Ciertamente los humanos somos “adversos al riesgo”, un riesgo que se maximiza cuando la informacion no es completa, y aún los propios gobiernos emiten mensajes dobles, quizás para tapar una crisis financiera mundial, que una pandemia de poca monta.
      Documentos de la propia OMS agradecen la colaboración de representante de laboratorios Roche y Novartis, en su insistencia de medicar con Oseltamivir, como si esto no implicara ningun conflicto de intereses.Esperable para una organización que recibe gran parte de su presupuesto de organizaciones no gubernamentales, dentro de las cuales, quienes más aportan son justamente las farmaceuticas.
      Nada malo tiene ganar dinero, por el contrario, quien esto escribe es partidario de mantener la propiedad privada, pero para todos, y no de privar de la propiedad a los menos tienen. Hace años ya que la industria farmacéutica está rompiendo los límites, generando enfermedades imaginarias, cambiando valores de laboratorio a través de consensos de expertos, y de esa manera medicalizar aún más a una sociedad. Sociedad que por otra parte se siente mas seguro con un medicamento. En este aspecto, y sin dudas, el oseltamivir como placebo social es altamente efectivo, y lo seria aun más si hay que pagar por el mismo los 50 dolares que cuesta, ya que está más que demostrado que frente a dos placebos, aquel que es más caro, mayor eficacia consigue.

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      Antigeno Prostatico Especifico: inutil para el cribado de cancer de prostata


      Todavia desconozco en que idioma hay que escribir esto, pero por enesima  vez sale otro articulo que dice que la PSA,  no tiene ninguna utilidad en el cribado de cáncer de próstata y que sólo sirve para el seguimiento de pacientes con Cáncer de prostata. El tema es simple. Se trata de una prueba inespecifica, y el famoso antigeno es volumen-dependiente del tamaño de la prostata. Por ende, en la natural evolucion que tenemos los hombres la prostata se agranda con la edad. Por tanto, ningun valor sirve para diferenciar si ese agrandamiento se  debió a la hipertrofia prostática benigna, que también es muy común luego de los 65 años. Por otro lado, un viejo anatomista,  Testut, ya escribia en su tratado que data del año 1900, que en sus autopsias encontraba un 100% de cáncer de prostata en hombres  mayores de 80 años. En otras palabras, y aunque los urólogos se empeñen en poner al cancer de próstata como un grave problema de salud, colocandolo entre las primeras causas de muerte, la realidad indica, que nos morimos más con cáncer de próstata que por el cáncer mismo. Por ende es un buen marcador de la evolución del cáncer pero no tiene ninguna utilidad, escrito en Inglés (también ha sido escrito en castellano, catalán, portugues, francés, ruso, y seguramente en esperanto) por el  British Medical Journal.
      Por ende tendremos que seguir lidiando con los expertos que aparecen en la prensa de todo el mundo, e intentan convencer a la gente de hacerse estos estudios desde los 50 años. 

      Utilizando una cohorte grande Seuca relacionada con un registro nacional de cáncer, los investigadores compararon los valores iniciales de PSA de aquellos que desarrollaron cáncer de próstata en el curso de 7 años post escrutinio, con otros hombres de similares características que no desarrollaron cáncer de próstata. La sobreposición de los valores de PSA frustraron los esfuerzos de los investigadores de encontrar un valor que tenga alta especificidad así como una sensibilidad del 50%. Sin embargo, notaron que un valor de PSA menor de 1 ng/mL virtualmente descarta el diagnóstico durante el período de seguimiento.

      Debido a los resultados de este estudio, se podría decir que los datos sobre los costos y beneficios de las pruebas de PSA permanecen insuficientes para apoyar el escrutinio masivo.

      Referencia: Benny Holmström, et al. Prostate specific antigen for early detection of prostate cancer: longitudinal study. BMJ. Septiembre 2009;339:b3537.

      La importancia de un certificado de ausentismo


      Diagnosis-specific sickness absence as a predictor of mortality: the Whitehall II prospective cohort study

      Jenny Headreader in medical and social statistics1Jane E Ferriesenior research fellow1Kristina Alexandersonprofessor2Hugo Westerlundsenior researcher3Jussi Vahteraresearch professor4Mika Kivimäkiprofessor1,4

      1 Department of Epidemiology and Public Health, University College London, London, 2 Department of Clinical Neuroscience, Section of Personal Injury Prevention, Karolinska Institutet, Berzelius väg 3, 171 77 Stockholm, Sweden,3 Stress Research Institute, Stockholm University, SE-106 91, Stockholm, 4Finnish Institute of Occupational Health, Topeliuksenkatu 41 aA, FIN-00250 Helsinki, Finland

      Correspondence to: J Head j.head@ucl.ac.uk

      Objective To investigate whether knowing the diagnosis for sickness absence improves prediction of mortality.

      Design Prospective cohort study established in 1985-8. Sickness absence records including diagnoses were obtained from computerised registers.

      Setting 20 civil service departments in London.

      Participants 6478 civil servants aged 35-55 years.

      Main outcome measures All cause, cardiovascular, and cancer mortality until 2004, average follow-up 13 years.

      Results After adjustment for age, sex, and employment grade, employees who had one or more medically certified spells of sickness absence (>7 days) in a three year period had a mortality 1.7 (95% CI 1.3 to 2.1) times greater than those with no medically certified spells. Inclusion of diagnoses improved the prediction of all cause mortality (P=0.03). The hazard ratio for mortality was 4.7 (2.6 to 8.5) for absences with circulatory disease diagnoses, 2.2 (1.4 to 3.3) for surgical operations, and 1.9 (1.2 to 3.1) for psychiatric diagnoses. Psychiatric absences were also predictive of cancer mortality (2.5 (1.3 to 4.7)). Associations of infectious, respiratory, and injury absences with overall mortality were less marked (hazard ratios from 1.5 to 1.7), and there was noassociation between musculoskeletal absences and mortality.

      Conclusions Major diagnoses for medically certified absences were associated with increased mortality, with the exception of musculoskeletal disease. Data on sickness absence diagnoses may provide useful information to identify groups with increased health risk and a need for targeted interventions.

      La importancia de un certificado de ausentismo


      Diagnosis-specific sickness absence as a predictor of mortality: the Whitehall II prospective cohort study

      Jenny Headreader in medical and social statistics1Jane E Ferriesenior research fellow1Kristina Alexandersonprofessor2Hugo Westerlundsenior researcher3Jussi Vahteraresearch professor4Mika Kivimäkiprofessor1,4

      1 Department of Epidemiology and Public Health, University College London, London, 2 Department of Clinical Neuroscience, Section of Personal Injury Prevention, Karolinska Institutet, Berzelius väg 3, 171 77 Stockholm, Sweden,3 Stress Research Institute, Stockholm University, SE-106 91, Stockholm, 4Finnish Institute of Occupational Health, Topeliuksenkatu 41 aA, FIN-00250 Helsinki, Finland

      Correspondence to: J Head j.head@ucl.ac.uk

      Objective To investigate whether knowing the diagnosis for sickness absence improves prediction of mortality.

      Design Prospective cohort study established in 1985-8. Sickness absence records including diagnoses were obtained from computerised registers.

      Setting 20 civil service departments in London.

      Participants 6478 civil servants aged 35-55 years.

      Main outcome measures All cause, cardiovascular, and cancer mortality until 2004, average follow-up 13 years.

      Results After adjustment for age, sex, and employment grade, employees who had one or more medically certified spells of sickness absence (>7 days) in a three year period had a mortality 1.7 (95% CI 1.3 to 2.1) times greater than those with no medically certified spells. Inclusion of diagnoses improved the prediction of all cause mortality (P=0.03). The hazard ratio for mortality was 4.7 (2.6 to 8.5) for absences with circulatory disease diagnoses, 2.2 (1.4 to 3.3) for surgical operations, and 1.9 (1.2 to 3.1) for psychiatric diagnoses. Psychiatric absences were also predictive of cancer mortality (2.5 (1.3 to 4.7)). Associations of infectious, respiratory, and injury absences with overall mortality were less marked (hazard ratios from 1.5 to 1.7), and there was noassociation between musculoskeletal absences and mortality.

      Conclusions Major diagnoses for medically certified absences were associated with increased mortality, with the exception of musculoskeletal disease. Data on sickness absence diagnoses may provide useful information to identify groups with increased health risk and a need for targeted interventions.

      Semiologia de laringe y Faringe


      http://tu.tv/tutvweb.swf?kpt=aHR0cDovL3R1LnR2L3ZpZGVvc2NvZGkvcy9lL3NlbWlvbG9naWEtZGUtbGFyaW5nZS15LWZhcmluZ2UuZmx2&xtp=489041

      This video demonstrates examination of the larynx and pharynx using indirect laryngoscopy, with either a simple dental mirror or a flexible fiberoptic endoscope.

      Holsinger FC, Kies MS, Weinstock YE, Lewin JS, Hajibashi S, Nolen DD, Weber R, Laccourreye O. N Engl J Med 2008;358:e2, January 17, 2008.

      www.Tu.tv

      Semiologia de laringe y Faringe


      http://tu.tv/tutvweb.swf?kpt=aHR0cDovL3R1LnR2L3ZpZGVvc2NvZGkvcy9lL3NlbWlvbG9naWEtZGUtbGFyaW5nZS15LWZhcmluZ2UuZmx2&xtp=489041

      This video demonstrates examination of the larynx and pharynx using indirect laryngoscopy, with either a simple dental mirror or a flexible fiberoptic endoscope.

      Holsinger FC, Kies MS, Weinstock YE, Lewin JS, Hajibashi S, Nolen DD, Weber R, Laccourreye O. N Engl J Med 2008;358:e2, January 17, 2008.

      www.Tu.tv

      British Medical Journal. Vol. 336. Núm. 7644


      British Medical Journal. Vol. 336. Núm. 7644

      Originales

      Ellis JM, Tan HK, Gilbert RE, Muller DPR, Henley W, Moy R et al. Supplementation with antioxidants and folinic acid for children with Down’s syndrome: randomised controlled trial. Págs. 594-597 R TC PDF

      Parkes G, Greenhalgh T, Griffin M, Dent R. Effect on smoking quit rate of telling patients their lung age: the Step2quit randomised controlled trial. Págs. 598-600 R TC PDF

      Editoriales

      Bize R, Cornuz J. Incentives to quit smoking in primary care. Págs. 567-568 TC (s) PDF (s)

      Reynolds T. Giving antioxidants to infants with Down’s syndrome. Págs. 568-569 TC (s) PDF (s)

      Ali A, Hassiotis A. Illness in people with intellectual disabilities. Págs. 570-571 TC (s) PDF (s)

      Melzer D, Hogarth S, Liddell K, Ling T, Sanderson S, Zimmern RL. Genetic tests for common diseases: new insights, old concerns. Págs. 590-593 TC (s) PDF (s)

      Revisiones

      Milton JC, Hill-Smith I, Jackson SHD. Prescribing for older people. Págs. 606-609 TC (s) PDF (s)

      Comentario

      Wilt TJ. Controversies in NICE guidance on prostate cancer. Págs. 612-614 TC (s) PDF (s)

      Práctica clínica

      Lip GYH. Don’t add aspirin for associated stable vascular disease in a patient with atrial fibrillation receiving anticoagulation. Págs. 614-615 TC (s) PDF (s)

      Guías de práctica clínica

      Graham J, Baker M, Macbeth F, Titshall V on behalf of the Guideline Development Group. Diagnosis and treatment of prostate cancer: summary of NICE guidance. Págs. 610-612 TC (s) PDF (s)

      UK experts call for national system to evaluate diagnostic tests


      UK experts call for national system to evaluate diagnostic tests

      Susan Mayor

      1 London

      the first 150 words of the full text of this article appear below.

      A national system should be introduced to evaluate diagnostic tests for use by the NHS, a report published this week recommends. It warns that currently no process is available for deciding which of the rapidly growing number of new tests should be used.

      Such an evaluation system should extend to tests and scans aimed at people who are well, making information available to the public to warn them that many of these tests are not useful and can be harmful, according to a second report.

      The first report, The Evaluation of Diagnostic Laboratory Tests and Complex Biomarkers, notes that about one billion laboratory tests are performed each year in the United Kingdom. “NHS laboratories have sophisticated systems to ensure the analytical accuracy of the tests, yet no system is in place to ensure the clinical effectiveness and utility of individual tests,” warned Peter Furness, consultant histopathologist at the University . . . [Full text of this article]

      Rapid Responses:

      Read all Rapid Responses

      Plain Films
      Stephen LITTLEFAIR
      bmj.com, 14 Mar 2008 [Full text]

      Impact of functional status at six months on long term survival in patients with ischaemic stroke: prospective cohort studies


      Texto Completo

      Karsten Bruins Slot, clinical research fellow1, Eivind Berge, senior consultant1, Paul Dorman, consultant neurologist2, Steff Lewis, medical statistician3, Martin Dennis, professor3, Peter Sandercock, professor3, on behalf of the Oxfordshire Community Stroke Project, the International Stroke Trial (UK), and the Lothian Stroke Register

      1 Department of Internal Medicine, Ullevaal University Hospital, NO-0407 Oslo, Norway, 2 Department of Neurology, Newcastle General Hospital, Newcastle upon Tyne, 3 Department of Clinical Neurosciences, Western General Hospital, Edinburgh

      Correspondence to: K Bruins Slot karsten.bruins.slot@medisin.uio.no<!– var u = “karsten.bruins.slot”, d = “medisin.uio.no”; document.getElementById(“em0”).innerHTML = ‘‘ + u + ‘@’ + d + ”//–>

      Objective To estimate the impact on long term survival of functional status at six months after ischaemic stroke. Design Prospective cohort study.

      Settings Three cohorts: Oxfordshire community stroke project, Lothian stroke register, and the first international stroke trial (in the United Kingdom).

      Participants 7710 patients with ischaemic stroke registered between 1981 and 2000 and followed up for a maximum of 19 years.

      Main outcome measures Functional status at six months after stroke assessed with modified Rankin scale or “two simple questions.” Mortality during follow-up. Survival analysis with Kaplan-Meier curves, log rank test, and Cox’s regression model.

      Results In a combined analysis of all three cohorts, among patients who survived to assessment six months after the index stroke, the subsequent median length of survival among those independent in daily living and those dependent was 9.7 years (95% confidence interval 8.9 to 10.6) and 6.0 years (5.7 to 6.4), respectively. In a combined analysis of the Oxfordshire and Lothian cohorts, subsequent median survival fell progressively from 12.9 years (10.0 to 15.9) for patients with a Rankin score of 0-1 at six months after the stroke to 2.5 years (1.4 to 3.5) for patients with a Rankin score of 5. All previously stated differences in median survival were significant (log rank test P<0.001). The influence of functional outcome on survival remained significant (P<0.05) in each cohort after adjustment for relevant covariates (such as age, presence of atrial fibrillation, visible infarct on computed tomography, subtype of stroke) in a Cox’s regression model.

      Conclusion Functional status six months after an ischaemic stroke is associated with long term survival. Early interventions that reduce dependency at six months might have positive effects on long term survival.

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      This article has been cited by other articles:

      Rodgers, H., Thomson, R. (2008). Functional status and long term outcome of stroke. BMJ 336: 337-338 [Full text]

      British Medical Journal. Vol. 336. Núm. 7636


      Originales

      Gates S, Fisher JD, Cooke MW, Carter YH, Lamb SEMultifactorial assessment and targeted intervention for preventing falls and injuries among older people in community and emergency care settings: systematic review and meta-analysis. Págs. 130-133 R TC PDF

      Graff MJL, Adang EMM, Vernooij-Dassen MJM, Dekker J, Jönsson L, Thijssen M et alCommunity occupational therapy for older patients with dementia and their care givers: cost effectiveness study. Págs. 134-138 R TC PDF

      Underwood M, Ashby D, Cross P, Hennessy E, Letley L, Martin J et al on behalf of the TOIB study teamAdvice to use topical or oral ibuprofen for chronic knee pain in older people: randomised controlled trial and patient preference study. Págs. 138-142 R TC PDF

      Editoriales

      Dieppe POsteoarthritis of the knee in primary care. Págs. 105-106 TC (s) PDF (s)

      Dixon JM, Montgomery DFollow-up after breast cancer. Págs. 107-108 TC (s) PDF (s)

      Revisiones

      Wilt TJ, N’Dow JBenign prostatic hyperplasia. Part 1—Diagnosis. Págs. 146-149 TC (s) PDF (s)

      Análisis

      Järvinen TLN, Sievänen H, Khan KM, Heinonen A, Kannus PShifting the focus in fracture prevention from osteoporosis to falls. Págs. 124-126 TC PDF

      Alonso-Coello P, López A, Guyatt G, Moynihan RDrugs for pre-osteoporosis: prevention or disease mongering?. Págs. 126-129 TC PDF

      Práctica clínica

      Wee B, Reynolds JH, Bleetman ARational Imaging: Imaging after trauma to the neck. Págs. 154-157 TC (s) PDF (s)