“Research highlights” is a weekly round-up of research papers appearing in the print BMJ. We start off with this week’s research questions, before providing more detail on some individual research papers and accompanying articles.
- Does intensive dietary advice improve glycaemic control in patients with poorly controlled type 2 diabetes?
- Is access to renal transplantation consistent across the UK for patients with end stage kidney disease?
- What is the efficacy of quadrivalent human papillomavirus vaccine in preventing low grade cervical and anogenital lesions over four years?
- Does the risk of neonatal death at term vary in relation to time and day of birth?
- Could the tendency of small trials to report larger treatment effects distort the results of meta-analyses in studies of osteoarthritis?
Time of birth, time of death …
A labour ward is a 24 hour environment, but the results of a study in this week’s journal suggest that it may not be consistently safe around the clock. In a retrospective cohort study, Dharmintra Pasupathy and colleagues looked at whether the risk of neonatal death varied according to time and day of birth among just over a million term babies born in Scotland between 1985 and 2004. After adjusting for several possible confounders, they found that babies born outside of the hours 09.00-17.00 Monday to Friday were more likely to die around the time of birth than those born during “office hours.” Out of hours deliveries were responsible for an additional one to two extra deaths per 10000 live births, with anoxia being the main cause of mortality.
Although the study was unable to determine the cause of the small but significant difference, it raised concerns that staff issues were at the heart of the problem – reflected by responses to the paper. Malcolm John Dickson, a consultant obstetrician/gynaecologist from Rochdale Infirmary, blamed the falling number of “flying hours” required to be senior resident on call for a labour ward. Monica Tolofari, a consultant midwife at Heart of Birmingham teaching PCT, asked how NHS maternity services can respond positively while considering the financial implications of changing shift patterns. For Pauline M Hull, editor of electivecesarean.com, the findings suggested a benefit of knowing who will deliver your baby and when – providing a retort to those who criticise as irresponsible the “convenience” factor of maternal request caesarean delivery.
Twenty four hour safety in the labour ward is a hot topic outside the UK too. The Netherlands lags behind in the steady decrease in perinatal mortality in western countries, and in 2008 health minister Ab Klink installed a steering committee on pregnancy and birth to come up with a solution. One of the key recommendations of their report in December 2009 was that gynaecologists and paramedics should be available for obstetric and perinatal care 24 hours, 7 days a week. When called, they must be able to reach the hospital within 15 minutes. Klink has pledged that extra funds will be provided where necessary to reach the target of decreasing perinatal mortality by 50%.
David Field and Lucy Smith conclude in their editorial that women should be informed about the risks and benefits of giving birth in different settings, even though the reasons for these variations remain unclear.
Dietary advice for diabetes
An intensive intervention of dietary advice may help patients with type 2 diabetes whose glycaemic control is poor despite optimised drug treatment, according to a randomised controlled trial reported by by Kirsten J Coppell and colleagues . Treatment options are limited for such people, but the authors said that the improvement in HbA1 levels seen in this study should encourage patients to modify their eating habits, though for many this would need to involve substantial change. Decreases in weight, body mass index, and waist circumference were other potential benefits seen in the group who received evidence based dietary advice, which took into account their food preferences and budget. In an editorial, Peter Clifton outlines other recent studies of dietary interventions in patients with hard to manage diabetes. He says that although these approaches showed some promise, their intensive nature and the need for specialist input are likely to drive up costs.
Access to kidney transplant
As a report from the King’s Fund (read more here and here) calls on the NHS to reduce variation in clinical practice, here’s yet more evidence that health care in the UK varies importantly from place to place. Rommel Ravanan and colleagues assessed equity in access to kidney transplantation at 65 renal centres in the UK. They found significant variability between centres, both for the time taken to activate patients on the waiting list and the time to receive a transplant, which couldn’t be explained simply by case mix. Inter-centre differences were more pronounced for access to kidneys obtained from live donors and after cardiac death, sources that are particularly likely to be affected by local practices and policies. The authors call for further research on whether the differences are due to variations in resources or whether certain centres are simply more organised.
Research online: For these and other new research articles follow this link
Do white matter hyperintensities matter?
As magnetic resonance imaging has become widely available and practised, clinicians often have to deal with incidental discovery of white matter lesions that appear as hyperintensities on images. Several studies have assessed the relation between these findings and cerebrovascular problems, with partly conflicting results. Stéphanie Debette and H S Markus systematically reviewed and meta-analysed longitudinal studies that examined the association between white matter hyperintensities and risk of stroke, dementia, and death, in the general population and in hospitals. They found that white matter hyperintensities indicate an increased risk of stroke, dementia, and death when identified as part of diagnostic investigations and their appearance should prompt detailed screening for risk factors.