JRSM short reports最新文献

Objectives: To investigate how distressing participating in medical research is perceived to be, compared to everyday events.

Design: Anonymous questionnaire.

Setting: Scotland and New Zealand.

Participants: One hundred members of the Scottish general public, 94 University of Auckland students, 22 New Zealand Ministry of Health ethics committee members.

Main outcome measures: Distress ratings made on a 0-10 scale for everyday events and common medical research procedures.

Results: Both general population and student samples generally rated the distress caused by participating in various medical research procedures as low or very low. Most research procedures were rated less than the distress caused by not being able to find a car park at a supermarket. In contrast, the ethics committee members rated the distress caused by most of the medical research procedures at a significantly higher level than the ratings of the student and general population samples. Ethics committee members overestimated the distress caused by interview or questionnaire assessments (M = 203.31%, SE = 11.42, 95% CI [179.79, 226.83]) more than medical testing for research (M = 158.06%, SE = 12.33, 95% CI [132.66, 183.46], p = 0.04) and everyday events (M = 133.10%, SE = 7.80, 95% CI [117.03, 149.16], p < 0.001).

Conclusions: Common medical research procedures are not rated as particularly distressing by the general public, and ethics committees may be adopting an over-protective role when evaluating research applications that involve the use of questionnaire or survey methodology.

Objectives: To assess patients' knowledge of their drug therapy for neovascular macular degeneration and to identify which aspects of the drug they considered most important if given the option of switching to an alternative drug.

Design: Prospective questionnaire survey.

Setting: Wolverhampton, England.

Participants: A total of 126 patients attending our hospital service for intravitreal ranibizumab therapy for neovascular macular degeneration.

Main outcome measures: Using a questionnaire, patients were asked questions pertaining to aspects of drug therapy in neovascular macular degeneration. Fields covered included drug names, knowledge of alternative drugs, cost of drugs and their views on switching to another drug.

Results: Eighty (63.5%) had heard of Lucentis (ranibizumab) and 31 (24.6%) were aware of Avastin (bevacizumab). Of the latter 31 patients, 20 did not have a preference between Avastin and Lucentis. These patients felt that the factors they would consider important for them to consider switching were effectiveness (10, 50%), specialist recommendation (8, 40%), safety (2, 10%) and cost (0).

Conclusions: Introducing a cheaper, off-label alternative in the therapy of macular degeneration in the presence of a licensed option has been extensively debated. Many patients have no knowledge of this controversial issue but it is likely that efficacy and recommendation by clinicians are more important than cost to patients who may consider switching to the off-label Avastin.

Objective: To investigate the rate of death caused by pulmonary embolism (PE) and the antemortem performance in diagnosis and treatment of PE.

Design: A systematic search of cases involving fatal PE via PowerPath® (Sunquest) followed by chart review.

Setting: An academic medical centre located in San Diego, United States of America.

Participants: Postmortem cases with pathological findings of PE.

Main outcome measures: After data collection and collation, the data were subject to analysis.

Results: From 2002 to 2012, PE was identified as the mechanism of death in 108 of 982 cases (11%, 95% CI 9.01-12.99%) at an institution with an average autopsy rate of 30% ± 0.07%. Excluding cases where care was withheld (by advance directive) or unavailable, 29 of 108 were eligible for antemortem treatment for PE. In 31% (nine of 29) of these cases the diagnosis of PE was considered antemortem. Only three of 29 were given thrombolytics despite only one case being contraindicated.

Conclusion: The rate of PE-related death is consistent with most other autopsy series and major epidemiologic studies despite advances in system wide deep venous thrombosis prophylaxis. The results validate previous studies that this diagnosis is often missed but probably improving compared to historical standards. Even when the diagnosis is considered, however, thrombolytics are not routinely given, even without contraindications. The cause of this failure to treat may require further study with comparison to patients that were treated to determine the utilization of this treatment. It also underscores the continued difficulty in the diagnosis of this disease.

Placebo appears to be a real neurobiological phenomenon that has evolved through the selection pressure to be able to heal ourselves. The complex language and social structures of humans means that we can attribute meaning to therapeutic encounters with culturally sanctioned authority figures and we can use our attachment to such figures to generate hope for recovery. Different mechanisms may be involved in the neurobiological aspect of placebo including anxiety, learning, conditioning as well as individual genetic variation. Examination of the published work shows that while some trials do seem to indicate a specific mode of action for homeopathic remedies other trials do not and this is an issue that needs to be addressed at the trial design stage. A clinical trial that includes both a placebo group and a non-participating control arm is the most powerful design for separating the non-specific and polymorphic placebo effect from the specific effects of trial medication. The control variables in a trial of homeopathic medication should also include the process of consultation as this may assume a meaning for the individual that can also be associated with a placebo effect.

Objective: To investigate whether measurements of junior doctor on-call workload and performance can clarify the mechanisms underlying the increase in morbidity and mortality seen after junior doctor changeover: the 'August effect'.

Design: Quantitative retrospective observational study of routinely collected data on junior doctor workload.

Setting: Two large teaching hospitals in England.

Participants: Task level data from a wireless out of hours system (n = 29,885 requests) used by medical staff, nurses, and allied health professionals.

Main outcome measures: Number and type of tasks requested by nurses, time to completion of tasks by junior doctors.

Results: There was no overall change in the number of tasks requested by nurses out of hours around the August changeover (median requests per hour 15 before and 14 after, p = 0.46). However, the number of tasks classified as urgent was greater (p = 0.016) equating to five more urgent tasks per day. After changeover, doctors took less time to complete tasks overall due to a reduction in time taken for routine tasks (median 74 vs. 66 min; p = 3.9 × 10(-9)).

Conclusion: This study suggests that the 'August effect' is not due to new junior doctors completing tasks more slowly or having a greater workload. Further studies are required to investigate the causes of the increased number of urgent tasks seen, but likely factors are errors, omissions, and poor prioritization. Thus, improved training and quality control has the potential to address this increased duration of unresolved patient risk. The study also highlights the potential of newer technologies to facilitate quantitative study of clinical activity.