Is more neonatal intensive care always better?

Despite high per capita health care expenditure, the United States has crude infant survival rates that are lower than similarly developed nations. Although differences in vital recording and socioeconomic risk have been studied, a systematic, cross-national comparison of perinatal health care systems is lacking. This study, in Pediatrics, looked at systems of reproductive care for the United States, Australia, Canada, and the United Kingdom, including a detailed analysis of neonatal intensive care and mortality.

The authors made a comparison of selected indicators of reproductive care and mortality from 1993-2000 through a systematic review of journal and government publications and structured interviews of leaders in perinatal and neonatal care.

Compared with the other 3 countries, the United States had more neonatal intensive care resources yet provided proportionately less support for preconception and prenatal care. Unlike the United States, the other countries provided free family planning services and prenatal and perinatal physician care.  The United Kingdom and Australia pay for all contraception. The United States has high neonatal intensive care capacity, with 6.1 neonatologists per 10 000 live births; Australia, 3.7; Canada, 3.3; and the United Kingdom, 2.7.

For intensive care beds, the United States has 3.3 per 10 000 live births; Australia and Canada, 2.6; and the United Kingdom, 0.67. Greater neonatal intensive care resources were not consistently associated with lower birth weight-specific mortality.

The relative risk (United States as reference) of neonatal mortality for infants <1000 g was 0.84 for Australia, 1.12 for Canada, and 0.99 for the United Kingdom; for 1000 to 2499 g infants, the relative risk was 0.97 for Australia, 1.26 for Canada, and 0.95 for the United Kingdom. Low birth weight rates were notably higher in the United States, partially explaining the high crude mortality rates.

In conclusion the United States has significantly greater neonatal intensive care resources per capita, compared with 3 other developed countries, without having consistently better birth weight-specific mortality.

Despite low birth weight rates that exceed other countries, the United States has proportionately more providers per low birth weight infant, but offers less extensive preconception and prenatal services. This study questions the effectiveness of the current distribution of US reproductive care resources and its emphasis on neonatal intensive care.

Ref: in PubMed

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Empirical treatment of suspected bacterial conjunctivitis

 This is an example of the evidence found in Clinical Evidence, a Journal from the BMJ Publishing Group. The Web page in particular is easy to navigate, based on organ group involved. It is especially useful for the section on potential harm, often forgotten when one looks for evidence.

Bacterial conjunctivitis is common and was therefore chosen as an example. Clinical Effectiveness found one systematic review with limited evidence from one RCT that topical norfloxacin increased rates of clinical and microbiological improvement or cure after 5 days compared with placebo.

The systematic review included 284 adults; 50% of the participants were culture positive). When comparing topical norfloxacin versus placebo It found that norfloxacin significantly increased rates of clinical and microbiological improvement or cure after 5 days compared with placebo.

They found no systematic review comparing both compounds but found 27 RCTs conducted in adults and children.  These RCTs found no significant difference between different topical antibiotics and each other in rates of clinical or microbiological cure.

There was one RCT (80 children). Which found no significant difference between polymyxin–bacitracin ointment plus oral placebo and topical placebo plus oral cefixime in clinical improvement or bacteriological failure rates.

One RCT identified by the review reported minor adverse events in 4.2% of people for norfloxacin compared with 7.1% for placebo. One non-systematic review reported four cases of aplastic anaemia with topical chloramphenicol and three cases of Stevens–Johnson syndrome with topical sulphonamides. However, the review did not report the number of people using these drugs, making it difficult to exclude other possible causes of aplastic anaemia.

Overall the placebo controlled RCT identified by the review did not assess the effect of topical antibiotics on antibiotic resistance. Most other trials included children as well as adults, and the ratio of children to adults was usually not specified.

The comparisons of lomefloxacin versus chloramphenicol and fusidic acid, the comparison of norfloxacin versus fusidic acid, and the comparison of tobramycin versus fusidic acid were single blind. One RCT found that a significantly greater proportion of participants rated topical tobramycin as more inconvenient than the viscous preparation of fusidic acid, because of a difference in the frequency of administration. The RCT also found that adherence among children was significantly higher with fusidic acid.

Ref: Clinical Evidence.

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Double breast removal

This is another in our occasional series from the National Electronic Library for Health. This news headline stated that women who are genetically prone to breast cancer can reduce their chances of developing the disease by 90% by having a double preventative mastectomy, reported The Times on 24 February 2004. This report accurately reflected the findings of a reliable research study of women with a specific genetic mutation.

This was a case control study of 483 women with BRCA 1/2 genetic mutations who had not developed breast cancer when recruited into the study. One hundred and five of these women underwent bilateral prophylactic mastectomy and the remaining 378 did not undergo the operation. The women had selected whether to undergo surgery or not. The two groups were matched for gene mutation type, research centre and year of birth. The women were followed-up for an average of 6.4 years.

This was a well-conducted case control study. The results of the study appear to accurately represent the reduction in risk to be expected in this group of women at very high risk of developing breast cancer. The sample used in the study appears to be representative of the population of women who need to attend high-risk clinics for genetic testing and discussion of risk-management options. The results of the study, however, cannot be extrapolated to the wider population of women without genetic mutation, who are at lower risk for the development of breast cancer.

Ref: web

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