Issue
14
Circumcision
- males in Bro Taf
There has been some media interest in the circumcision of boys by NHS
surgeons, making the point that the operation should be rare, but that where it was
indicated, it should be performed by a paediatric, not a general surgeon.
This seems to make sense. We decided therefore to look at male
circumcision rates in Bro Taf, to see if there was any difference in the way such cases
were managed in the four unitary authority, shortly to be Local Health Group areas. Fig.1
shows the rates of circumcision performed on the NHS in Bro Taf last year. It appears that
Merthyr has much higher rates that other areas of Bro Taf or the English figure. This
needs further investigation.
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Too much surgery in dying
patients
A BMJ article in November reported the National Confidential Inquiry
into Perioperative Deaths had the above striking headline. The inquiry team, which
collects data on patients who die within 30 days of a surgical procedure, looked at 2541
deaths in detail to see what lessons could be learned for the future. These deaths
represented 13% of the 19,496 perioperative deaths reported during the year April 1996 to
March 1997.
The message that recurs throughout the report is that surgeons need to
be clear about the aims of surgery. "A decision to operate may not be in the best
interests of the patient," the report says.
This applies across specialties. In gynaecology, the report says:
"Surgery for benign disease can have a poor outcome if the age, physical status of
the patient and the type of hysterectomy are not taken into account."
Similarly, the experts feel that percutaneous endoscopic gastrostomy is
being performed on too many patients with a very short life expectancy. "A
percutaneous endoscopic gastrostomy was performed in situations where symptom control
right have been more relevant," it says.
Ref
(web)
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Damn Volvo has its
lights on
A recent Bandolier mentions the work going on in Wales, led by Ronan
Lyons, to gather evidence on injury prevention strategies and categorised it in terms of
the strength of evidence and whether interventions are beneficial or harmful (http:
/www.uwcm.ac.uk / uwcm / lib / pep). One item of special interest was the question of the
use of running lights on cars in daytime.
All the known studies on the use of daytime running lights were collected in a
met-analysis. Some of these were randomised (some cars had lights on, others did not,
usually from a fleet of cars), some were before-and-after studies with a comparison group,
and some were simple before-and-after studies, for instance when a new law came into
force.
The outcome was accidents occurring in daytime between cars, or between
cars and pedestrians or cyclists. The effect was about a 15% reduction in accident rates.
The beneficial effects were maintained whether the proportion of cars using lights was
30 or 50% at the start of a study, and from 60% to 95% at the end. The review makes a good case that using
daytime running lights right now in the UK should reduce the effect of an accident for an
individual car of about 15%.
Ref
to Bandolier homepage
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Randomisation worth the
effort?
Those of us who have spent much time attempting to set up randomised controlled trials
often wonder if its was worth all the fuss (after all Archie Cochrane did his best work on
cohort studies). It is therefore cheering to read in the BMJ back in October that it is.
They reported eighteen studies that compared randomised controlled
trials with non-randomised controlled trials or trials that were more adequate in terms of
randomisation compared with those which were less adequate.
Failure to use random allocation and concealment of allocation were
associated with relative increases in estimates of effects of one treatment or the other
of 150% or more. The authors conclude that not using concealed random allocation can
distort the apparent effects of care in either direction, causing the effects to seem
either larger or smaller than they really are.
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Randomised Trials
improving?
While on the subject of randomised controlled trials (RCTS) the October issue of the
BMJ which looked at trials had another fascinating article.
This study examined 2,000 controlled trials on the treatment of schizophrenia over the
last 50 years. Most trials are undertaken in North America. The United States, in
particular, has a strong tradition of evaluative research but only 2% of the world’s
population of people live in North America. How applicable the findings of these trials
are to the 43 million other patients in Africa, Australasia, and Europe is difficult to
assess.
The quality of reporting in this large sample of trials was poor and
showed no sign of improvement over time. As low quality scores are associated with an
increased estimate of benefit, schizophrenia trials may well have consistently
overestimated the effects of experimental interventions.
Drug treatments are the bulwark of treatment of schizophrenia, so it is not surprising
that drug trials dominate the sample. Most important drug trials in recent years use
haloperidol as the control. This is likely to be a potent cause of adverse effects so if
the new experimental drug has moderate antipsychotic properties, favourable outcomes can
be expected. Comparisons with other old, but less toxic, antipsychotic drugs are rare.
Further difficulties with using the evidence generated by this mass of research are that
the studies are of limited duration for an illness that often lasts decades.
The findings of this survey are as bad, if not worse, as those for
other disciplines of health care. There is great scope for well conceived, conducted, and
reported trials.
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Acute Otitis
Media
A search sought randomised trials comparing different durations of
antibiotic treatment in children with a diagnosis of acute otitis media. Thirty two trials
were found and included.
The results showed that long courses of antibiotics confer little, if
any, benefit over short courses. The fact that there was a benefit in the trials at 8-16
days is probably more of a reflection of the fact that the long course is only just
completed and does not allow for any recurrence in the time.
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